Stalled talks put Blue Cross Blue Shield of TX patients through ‘absolute hell’

Eight years ago, Melissa Dossey contracted sepsis. Doctors were never able to pinpoint the cause, but during treatment her extremities lost oxygen for so long that she had to have both hands and both feet amputated.

As a quadruple amputee, Dossey, 42, continues to receive twice weekly physical therapy sessions and sees her primary care physician and specialists regularly.

So it was “devastating,” she said, to hear on Tuesday, April 1, that her private health insurer, Blue Cross Blue Shield of Texas, had failed to reach a new contract with Southwestern Health Resources, the hospital network where she receives care.

“It really was about 72 hours of absolute hell,” Dossey said in the sunlit kitchen of the expansion onto her parents’ North Richland Hills home where she lives and receives round-the-clock assistance from her brother-in-law.

Blue Cross Blue Shield reached a new deal with Southwestern Health late on Friday, April 4, but not after causing significant distress for Dossey and many others who found themselves in a similar situation that week.

The Star-Telegram received over a dozen emails from Blue Cross Blue Shield policyholders whose care was affected or feared it could be. Their responses ranged from frustration at having to find new health care providers to panic over where to turn. More than one had received cancer diagnoses in recent weeks.

A Blue Cross Blue Shield spokesperson said in an emailed statement the company “works on behalf of our members and customers to reach contract agreements that provide them access to quality health care while protecting them from escalating health care costs.”

When members lose in-network coverage at hospitals, “it’s often because we cannot reach an agreement that ensures our customers cost-effective access to quality care,” the statement said.

The statement also said that Blue Cross Blue Shield notified policyholders with ample time to find other in-network providers and that it offered continuity of care for members with certain conditions, including pregnancy, terminal illness and others.

A spokesperson for Southwestern Health Resources said in a statement that the network regrets the frustration caused by the uncertainty. The statement highlighted the new contract’s retroactive effectiveness, meaning policyholders will not “experience any lapse in coverage or greater financial burden” for care received in the days before they reached a deal.

“We tried to minimize disruptions by prioritizing continuity-of-care provisions for conditions such as cancer and pregnancies and allowing visits to continue during the temporary out-of-network period, reducing the need for appointment cancellations,” the statement said. “We’re grateful that everyone can now focus fully on what matters most — their health.”

The policyholders with the affected plans who contacted the Star-Telegram did not say they had received advanced notice or continuity of care.

Dossey receives physical therapy for a new pair of prosthetic legs. She was able to see her therapists during the week, but was told they would be her last in-network sessions if a new contract was not reached.

She did not want to have to look elsewhere for care.

“The place I go to for physical therapy, it’s the best physical therapy facility I’ve found, unless I want to drive super far away,” she said. Her hospital is a close drive from her home, and being forced to get care farther away would be a burden to the family members she depends on to get there. “So to have that put in jeopardy was very upsetting.”

Dossey and others who spoke to the Star-Telegram about their experiences said they felt like the victims of an industry that prioritizes profits over patients.

She thought Blue Cross Blue Shield of TX had her covered. ‘Then this happened’

Melanie Perry didn’t pay attention to the bills during her chemotherapy. Thinking about the cost of care was too much at an already overwhelming time in her life.

“You’re sitting there getting chemo for two hours, and you don’t realize it’s $25,000,” she said during an interview at her place of work in Arlington.

Perry was diagnosed with breast cancer last year. She’s six months out of chemo, but she continues to receive treatment and will soon begin another to avoid the cancer coming back in her bones. One of her medications costs $17,000 a month, and she does not know what the new treatment will run her. She has monthly appointments with her oncologist, and was trying to catch up on routine care she missed because of the chemotherapy when the contract expired.

Her employer switched to Blue Cross Blue Shield at the beginning of the year in order to keep UT Southwestern, where she receives treatment, in network.

“I think I’m covered because, you think, oh, Blue Cross, Blue Shield, that’s one of the biggest, one of the best, there’s no problems — and then this happened,” she said.

A routine colonoscopy that had been pushed back since the pandemic was canceled after the contract expired. Her appointment scheduled for April 11 was pushed back to July in hopes the insurer and the hospital network would reach a new deal.

“So now I’ve got another three months to be apprehensive about it,” she said. “I just was ready to get it just done with and go on.”

While the disruption to her care only affected routine treatment, Perry wonders what would have happened if the contract negotiations had broken down when she had her mastectomy.

“I thought, well, what if this would have happened at the beginning of last year, and I’m ready to go into surgery?” she said.

The power that companies like Blue Cross Blue Shield have over patients is ‘scary’

Two years ago, Hunter Mixson was playing soccer when he started to feel a pain in his chest. He came off the field, sat down and collapsed.

He went to the hospital, but doctors were unable to tell him what was wrong with him. The next day, he had a full-blown heart attack.

He was 29 years old.

Mixson needed emergency open-heart surgery to bypass two arteries. He was diagnosed with spontaneous coronary artery dissection, a rare condition in which a tear forms in a coronary artery and causes blockage.

“It’s not a typical cholesterol blockage, so it’s not something that can be seen,” he said during a break on a recent day on the job. He owns his own landscaping company based in Keller. “It happens randomly, and there’s no way to tell that it’s going to happen.”

Mixson took three months of cardiac rehab three times a week after the surgery in order to get back to his regular exercise routine. He now runs seven miles a week and still receives ongoing care for the condition, regularly seeing a cardiologist and a heart failure specialist.

While the contract expiration did not end up disrupting his care, the possibility of having to find replacements for all of his physicians brought him distress and worry.

“It was very stressful,” Mixson said. “We started the process of narrowing down who we might call and seeing what doctors were available.”

Like others, he chose Blue Cross Blue Shield for its broad network of health care providers, so he was sure he would have been able to find adequate care had a new deal not been reached. But that wasn’t the issue.

“I think there are good options, but it’s just going through that process and the time,” he said. “I’m out here working all day. I don’t have the luxury of someone that might be in an office or that might have a couple hours in the day to handle that situation. … It was unexpected.”

He feels lucky to have his mother to help him with such issues, but he was worried about how long the process would take and how it might affect his work.

Like the others interviewed for this story, Mixson said he understands that companies need to make money, but he feels that patients should be the industry’s priority.

“I think the main focus should be the health of the general population, rather than making someone’s wallet a little fatter,” he said. “It’s scary to see that corporations can have that power.”

‘Patients can get squeezed’ because of health insurance contract negotiations

What happened here in North Texas last week is an “increasingly common phenomenon,” according to Jean Abraham, head of the Division of Health Policy and Management at the University of Minnesota.

“It really very much reflects our private market for health insurance, where large private insurers are needing to create a network of providers that’s part of managed care plans,” she said in an interview.

Such negotiations often center on health care rate increases, she said, but they can also involve other factors like timing of claims payments or issues like prior authorization, by which a health insurance plan reviews and approves certain treatments before they are provided.

“But it does put the patient in a not great place, since they are often caught in the middle, and really their goal is to be able to access care,” she said.

Speaking with the Star-Telegram last week about what policyholders could expect when the contract expired, Jonathan Gruber, a health care economist at the Massachusetts Institute of Technology, said the high rates providers can charge in the non-competitive health care market are to blame for such negotiations breaking down.

“In Europe, this doesn’t happen because prices are regulated, and there’s not excess profits to be had,” he said in an interview. “Here, we try to let the market set prices, but the bottom line in economics is a competitive market sets prices well. A non-competitive market does not set prices well, it sets prices that allow for excess profit.”

He argued that the contract expiration is one of an increasing number of examples of why the government should regulate prices.

Dossey, Perry and Mixson all said they feel the government should regulate health care prices as well.

No easy task on this side of the pond, Abraham said.

“Patients can get squeezed” by contractual disputes, she said. “But it’s very, very challenging politically to argue to move away from a market-based system. I think this country has always struggled with that.”

When Perry began to stress about how the contract expiration might affect her breast cancer treatment, she called her big sister, a former cardiologist: “She said, ‘That’s the game they play.’ And she said, ‘It’s very sad, yeah, but ‘You’re not a person, you’re a dollar sign.’”

The squeeze made her feel “helpless,” Perry said. “You can’t fight the system. You can’t go up against either company that’s that big.”

Dossey used the word “disenfranchised.”

“It’s just a private company doing what a private company wants to do and making money off of people like me,” she said. “I just feel like there’s a disconnect between those people and the people who have insurance from them … like there’s this huge lack of empathy, lack of curiosity about the people off of whom they make the money.”

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