Christus, Prestyberian provider dispute limits hospital access for 2K seniors

Sept. 17--Some 2,000 Santa Fe County seniors may have to look for new health care providers because two of the state's largest nonprofit health care organizations couldn't reach an agreement on doctor and hospital services.

Medicare Advantage patients in Northern New Mexico under the Presbyterian Health Plan received notice this week that they no longer will be able to access Christus St. Vincent Regional Medical Center or its physician and specialty network after the end of the year.

The patients can use the hospital and its network until then -- and emergency care will always be provided at Christus, which operates Santa Fe's only general hospital. But the cost of elective surgery, as well as the wide assortment of primary and specialty services offered by the Christus physician network, will not be reimbursed starting Jan. 1. Instead, Medicare members will have to find a Presbyterian network physician in Santa Fe, Española, Rio Rancho or Albuquerque, or choose another insurance plan.

As competition for health care dollars intensifies, the dispute is the latest between two companies that are trying to expand services to meet more demand in Santa Fe while keeping a lid on costs -- sometimes at the inconvenience of patients.

"I now have three specialty doctors I will not be able to use in Santa Fe because of this change and finding replacements in Albuquerque as a new patient could take months before I can get an appointment," said one man who sent an email to The New Mexican.

Lisa Lujan, president of Presbyterian Health Plan, said, "We're hopeful that some of these members will make a decision to stay with Presbyterian, even if it means maybe additional travel to Española or Albuquerque." A wide spectrum of specialty services are available within an hour's drive of Santa Fe, she said, with increasing coverage through Presbyterian's new clinic on St. Michael's Drive and at Presbyterian Hospital in Española.

Presbyterian's Medicare plan recorded 250 overnight stays at Christus St. Vincent Regional Medical Center in the most recent plan year. About 1,000 members received specialty care from Christus doctors, and another 300 saw a Christus physician for primary care, according to numbers provided by Presbyterian.

Lujan said there are always issues over reimbursement levels in certain communities, but the discussions between the two big health care organizations never even came down to that. Christus St. Vincent just informed Presbyterian in June that it would not participate in its Medicare plan.

"In terms of a sole community provider with a large physician presence making a decision not to participate, this issue is unique," Lujan said.

Lillian Montoya, vice president for public policy at Christus St. Vincent, said physician visits and specialty care have always been out of network for the Presbyterian members -- something Presbyterian disputes.

"We looked at our other agreements," Montoya said, and there are "five other options for seniors to continue to see the same physicians and pay in-network" by using other Medicare programs, including the Christus Health Plan launched last year.

Montoya said Presbyterian's reimbursements "weren't as competitive as the other insurers" under contract with Christus.

According to Lujan, Christus specialists currently are out of network only for Presbyterian's newest Advantage product, but Presbyterian has been a "longtime participant for our Medicare Advantage PPO members. All of our Medicare Advantage members currently have access to hospital services."

The agreements were due to end Oct. 1, but both sides have extended coverage for the patients until Dec. 31 -- when patients might be able to enroll in a new health insurance plan for the 2016 calendar year. Other Presbyterian plans with private companies or Medicaid are not affected by the change, and those Christus contracts remain in place.

The Christus St. Vincent network is the major health provider in Santa Fe County, with a wide network of specialty services. The nonprofit has contracts with many insurance companies that do not have on-the-ground services here but may have insured patients in Santa Fe, such as as Blue Cross Blue Shield of New Mexico and United Healthcare.

Though Presbyterian has opened a clinic in Santa Fe that includes urgent care and limited specialists (cardiology, OB-GYN and neurology), it has maintained contracts with Santa Fe doctors and with Christus to fill gaps where it cannot provide direct services -- the biggest of which is hospitalization.

Presbyterian Health Plan is the insurance arm of Presbyterian Healthcare Services. Together the organizations have 450,000 insured members and 10,000 employees, with clinics and hospitals across the state.

Last year, Christus began offering its own Medicare Advantage Plan serving seniors in Santa Fe, Los Alamos and San Miguel counties, so the organization might have less incentive to negotiate with another direct provider -- especially one that has expanded its footprint in Santa Fe.

The website for Christus Health Plan advertises "a new Medicare Advantage plan that allows you to keep your doctors and use the hospitals that are close to you."

"Christus has its own health plan and that may be why [they didn't want to negotiate]," said Mary Feldblum, who is part of a movement to build a single insurance co-op for the state, The Health Security for New Mexicans campaign. "With a monopoly in some areas, there is less incentive to negotiate."

Feldblum said the dispute comes on the heels of a decision by another insurer in the state, New Mexico Health Connections, to no longer give its customers the option to enroll in preferred provider plans, under which patients can choose their own doctor.

Instead, patients will be restricted to contracted medical providers.

With the recent creation of federal and state insurance exchanges, consumers can compare plans and prices side by side. That has made it more difficult for insurers to raise premiums, so firms have to keep a lid on costs by limiting access to certain providers and hike copays and deductibles.

"The name of the game is have the consumers pay more out of pocket and restrict the network of providers," Feldblum said.

Lisa Reid with the state Office of the Superintendent of Insurance said insurers are required to have a reasonable network of specialists and a licensed acute-care hospital "no greater than 30 miles or 30 minutes" for 90 percent of their covered members.

The state is looking to tighten some of the guidelines, she said, and develop a database that would allow better oversight.

She said that when consumers purchase insurance, they need to be diligent in checking on whether the doctors, clinics and hospitals they prefer are included in the network. She said those insurance customers who feel the networks are not adequate can file a complaint with the state insurance superintendent.

Both Christus and Presbyterian are nonprofits with origins in Christian churches that came to New Mexico to extend healing missions to underserved communities in the West.

Contact Bruce Krasnow at 98603034 or [email protected].

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