Affordable insurance, but at what cost?
By Carson Gerber, Kokomo Tribune, Ind. | |
McClatchy-Tribune Information Services |
But when you choose your insurance company, you make another choice. It's one you may not even be aware of.
You choose which hospital you can go to.
That's because the two hospitals in
It's a simple breakdown. If you pick Anthem, you can only go to
If you pick MDwise, your coverage is limited to
It's a scenario that creates a stark gap for area patients going through the healthcare.gov website, where users access the exchange.
"This has really put a dividing line between the two facilities in the community," said St. Joseph President
It's a divide
Davis, a 54-year-old crossing guard and cafeteria worker at
But she had forgotten about her cancer doctor, whom she's seen every six months for the last five years after beating breast cancer with a host of chemotherapy and radiation treatments.
That doctor practices at Community Howard.
"I didn't think about that at the time I signed up, because I only see her every six months," Davis said last week.
She said she really liked each doctor. But by signing up through the exchange, Davis couldn't see both.
"I'm pretty frustrated," she said. "It's really hard to make a decision, but I guess you have to stick with the doctor who means the most to you."
In the end, Davis scrambled last week to switch her insurance from MDwise to Anthem before Monday's enrollment deadline so she could continue seeing her cancer doctor at Community Howard.
But after that, the issue of choosing a doctor disappeared. Davis learned she didn't qualify for the exchange like she previously thought because she didn't make enough money. Now, Davis said she's applied to get coverage through the state's program for uninsured adults, the Healthy Indiana Plan.
But the fact remains: By signing up for insurance through the exchange, patients by default have just limited their health-care choices.
Smaller, leaner, cheaper
Getting stuck with just one hospital or network through the exchange isn't an issue just in
It's a trend that's exploded onto the national health-care scene over the last year, as insurance companies and hospitals try to assimilate to new requirements and policies laid out in the Affordable Care Act (ACA), otherwise known as Obamacare.
Insurance companies that decided to enter the healthcare.gov marketplace get a premium from the federal government to help with coverage costs, but they only get so much money, Norrell said.
"Insurance providers have to be very judicious about how they pay that money out," he said.
To keep prices low and competitive on the exchange, insurance companies approach only a small number of networks offering substantially lower payments.
The hospitals might not get as much money from the insurance company, but what they do get are loads of new customers who signed up through the exchange and will only be using their facilities, physicians and specialists.
"This is an easy way to, with just one signature, get thousands of new patients," Norrell said.
It's also a win for the hospital because many of those people getting insurance through the exchange never had it before, but were still using the hospital's services essentially for free.
"Even though the insurance company's exchange products have low payout rates to the hospitals, it's better than getting nothing from uninsured patients," Norrell said. "Anything is better than nothing."
The narrow-network approach to the exchange is an appealing model for how hospitals and insurance companies deal with each other, and it's becoming the national norm.
A study by the
"There's no question. It's a cost standpoint," he said.
There was also the fact that only two insurance companies decided to join the exchange in
"I wish I could tell you it was more scientific, but basically it came down to did we want to choose zero, one or two providers," Schlagenhauf said. "We felt comfortable with Anthem, because they already know how to market to their customers ... But we were a little surprised that so few commercial plans decided to get into the exchange business."
There's no doubt it makes financial sense for insurers to offer smaller networks in their policies, and IU's Norrell said it may even be necessary for their survival within the exchange.
"It's not callous disregard by insurance companies," he said. "They have to create these narrow networks to make the numbers work."
That may be so, but the rapid exodus to narrow networks may be bad news when it comes to patients' options.
Limiting access?
The decision by each health network to take only one insurance company represents a major break from how commercial insurance traditionally works, said Community Network's Schlagenhauf.
When customers are picking insurance providers outside the exchange, it's usually based on the quality of the policy and the kind of coverage it offers.
The question of where patients will get treated is a secondary one, since the majority of hospitals, including
But customers picking insurance through the exchange can't just look at the policy anymore; they also have to consider the quality of health care and the services offered by each hospital and pick their insurance based in part on that.
St. Joseph President
Both provide services such as heart and cancer care, maternity facilities and outpatient services. The size and scope of those services may vary at each hospital, but they're all there.
With that in mind, Young said narrow networks moving into
"This is changing how people will make health-care decisions," she said. "I don't know that it's limiting health care, but it changes their access ... It really comes down to who do you want as your provider, and how much do you want to pay? But it is limiting your choices."
Community Network's Schlagenhauf agreed, adding the move to narrow networks doesn't change the quality of care offered at Community Howard or the relationship between the two hospitals in
"The facilities certainly compete for business, but I don't know that the exchange increases that competition," he said. "It's a new product, and in time, we'll understand how it plays in the
One service that won't be affected by the area's narrow networks is emergency care. Young said insurance providers are required to cover true emergency treatments, regardless of which hospital patients go to.
Once the emergency situation is under control, however, she said it's up to the hospital to check if a patient's insurance would cover an extended stay at its facility, or if a person should be moved to another hospital covered by the patient's insurance.
In the end, what narrow networks really offer is a tradeoff, said
The narrow networks in
"Those people certainly aren't complaining," she said. "The people who never had insurance or even the chance to have it, they're absolutely thrilled to have coverage ... They're not as concerned as others about where they're getting covered. They're just happy to be covered."
"We have to keep the big picture in mind," he said. "By insurance companies moving to a narrow network, we're providing many people with insurance who have never had any. Restricted access is better than no access at all."
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