Carol M. Ostrom, The Seattle Times, Author at ��ϳԹ�� News

For Medicaid Patients, Access To Primary-Care May Not Be As Advertised

Carol M. Ostrom, The Seattle Times — Wed, 14 May 2014 14:09:00 +0000

This story was produced in partnership with

Using “mystery shoppers” looking for access to health care, Public Health – Seattle & King County has found troubling indications that access to primary-care providers may not be as advertised.

About half the time, primary-care providers listed as accepting new patients on Medicaid managed-care organization websites in fact told the “shoppers” they were not accepting new Medicaid patients.

The initial survey was conducted over a 10-day period in early December. A random sample of adult primary-care providers was selected for each of the four regions of King County, and callers used the online provider directories of the five that serve King County.

The “shoppers” were staff of a survey consulting firm, but told the doctors’ offices they were uninsured patients in the process of deciding what kind of health insurance to get.

They then asked if the provider was accepting new patients for Medicaid (Apple Health) managed-care plans.

King County added about 80,000 new adult Medicaid clients over the past six months, surpassing the state’s 2018 enrollment target.

Two University of Washington Master in Public Health students working under the supervision of Public Health epidemiologist Eli Kern conducted a follow-up, which is just concluding.

The information, to be presented to the on Thursday, is one part of an assessment of the success and the impact of the county’s effort to enroll the uninsured in health insurance, both private and public, made available through the Affordable Care Act.

Overall, more than 165,000 county residents were enrolled in health insurance during the campaign, which was fueled in part by knowledge of the county’s noteworthy income disparity.

According to Public Health, King County, among the 15 largest U.S. metropolitan areas, has the widest income disparity between those who do and don’t have health insurance.

“We did our homework before the enrollment season started — and we knew that in some communities in King County more than a quarter of adults were uninsured,” said Dr. David Fleming, director and health officer for Public Health – Seattle & King County, in a statement. “So we made certain community groups active in those areas got involved in helping people sign up.”

Board of Health members will also hear a report by Jasmine Hutchinson, a master’s degree candidate from the University of North Carolina at Chapel Hill, who studied the strategies used by King County, which was picked by the to lead county enrollment efforts.

Among states that expanded Medicaid and created a state-based exchange, Hutchinson calculated that Washington’s enrollment, as a percentage of those potentially eligible, was bested only by Massachusetts, Rhode Island and Vermont.

Among Hutchinson’s conclusions: King County showed that six practices can have a major impact on such an effort and may provide a model for others.

• Solicit active support from local leaders, and create opportunities for them to lead.

• Invite non-health related organizations to participate.

• Build on existing partnership networks and bring them — particularly the smaller ones — to the table.

• Let grassroots organizations make the detailed decisions.

• Talk about enrollment in terms that resonate with communities.

• Convene a regular forum for those assisting with enrollment to address technical issues and solutions.

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Many Wash. Health-Exchange Plans Exclude Top Hospitals From Coverage

Amy Snow Landa — Tue, 03 Dec 2013 06:01:00 +0000

This story was produced in partnership with

When Bev Marcus began shopping recently for a health-insurance plan, she found one from Premera Blue Cross on exchange that seemed to offer good coverage at a reasonable price.

Marcus assumed the individual Premera policy would include main hospitals in Seattle, just like the Premera group plan she and her husband had in the past.

That policy had covered most of $150,000 in hospital bills from her husband’s heart attack and cancer treatment a few years ago. Marcus knew she wouldn’t want to face such bills without coverage, so she called Premera to make sure the Swedish hospitals were in its network.

The answer startled her: None of the company’s individual plans for 2014 include any of Swedish’s three hospitals in Seattle or its campus in Issaquah.

“I said, ‘Whoa! You’ve got to be kidding,’ ” Marcus recalled.

But it’s no joke: Many insurers offering plans through the Washington Healthplanfinder, the exchange marketplace where shoppers can apply for subsidies, are using narrow provider networks. These networks are not the broad, include-all-providers networks that many big employer plans currently enjoy.

Kenneth Pick and his wife, Bev Marcus, compare health plans in their Seattle home. They are urging others to carefully look at their plans network to avoid unwelcome surprises (Lindsey Wasson / The Seattle Times).

Premera says its pared-down “value network” helps contain costs, keeping plans affordable for people who must buy their own insurance. And while skinnier networks may not always equal lower premiums, with the fewest in-network hospitals, also has the lowest prices.

If a patient needs a covered service, such as a heart transplant, but it’s not provided at in-network hospitals, insurers must cover it elsewhere.

But for patients in other circumstances, plans with lower premiums could end up costing more if they receive care from a provider outside their plan’s network.

Not only could they wind up paying most or all of the bill, they would lose the law’s cap on out-of-pocket expenses.

Premera, for example, limits annual out-of-pocket costs for in-network care at $6,350. But out-of-pocket expenses for care outside the network are “unlimited.”

Marcus and other consumers have been surprised to learn that hospitals they assumed would be in-network for major plans are not.

The Seattle retiree supports the , which established the exchanges and requires insurers to take anyone regardless of health condition. Still, she’s telling everyone she knows to to find out which hospitals are included.

“I’m nervous that people will sign up for plans and not realize they’re not covered,” she said. “If you’re not capped, you could lose your home.”

Left out of exchange

The narrow networks have prompted pushback from some providers, notably . It filed suit in October against the state insurance commissioner, demanding he remove from the exchange five insurers that do not include Children’s in their networks. (n and Children’s have only a verbal agreement at this point.)

Hospital officials say it is “unprecedented” for major insurance plans in the local market to exclude the region’s top pediatric hospital.

But Children’s is not the only hospital left out of most exchange plans.

The Seattle Times asked the seven insurance companies selling individual policies in the exchange in King, Pierce and Snohomish counties to list their in-network hospitals.

The results show that only one — — includes , which offers treatment for some of the most complex cancer cases in the region.

Four of the seven insurers do not include the or the — which has the state’s only Level 1 trauma center and burn unit.

Community Health includes every major hospital in King, Pierce and Snohomish counties, but is the only exchange insurer that does.

By contrast, Premera and its subsidiary, , include many major hospitals, but not the largest Seattle-area hospitals in the two major medical systems — Swedish and UW Medicine.

, an affiliate of , does not include any Swedish hospitals but includes all of the UW hospitals. Coordinated Care, on the other hand, includes all of the Swedish hospitals but no others.

Dan Dixon, a Swedish vice president, said discussions with Premera continue. “You captured us at a moment in time,” he said. “We’ll get there sooner or later.”

Impact on doctors

Doctors are starting to realize that when a hospital is cut out of a plan’s network, they also are affected.

At Seattle’s , a large multispecialty group, the excision of Swedish hospitals from three major insurers’ exchange-plan networks is causing some heartburn.

Polyclinic’s ob-gyns have delivered most of their babies at Swedish for years. Now, they’ll have to make other arrangements, but it’s complicated.

Premera and LifeWise have only one downtown Seattle hospital in their networks — — and it doesn’t deliver babies. And unlike Swedish, Virginia Mason doesn’t use the same electronic records systems.

“We’ve spent hours thinking: ‘So what do we do?’ ” says Polyclinic spokeswoman Tracy Corgiat. “We have evaluated — specialty by specialty — how we will handle patients who cannot be admitted to Swedish because their insurer won’t cover it.”

Somehow, they have to urge patients who are pregnant — or may become pregnant — to choose their individual plan carefully if they want a Polyclinic doctor and a Swedish delivery. Only one in-exchange insurer, Community Health, and one nonexchange insurer, Regence, cover that combination.

Patients like Marcus’ husband, Kenneth Pick, 60, whose Polyclinic doctors admitted him to Swedish, face another challenge.

Only one cardiologist at Polyclinic now has privileges at Virginia Mason, and others are applying. But Corgiat said it’s really difficult for doctors to cover more than one hospital because privileges come with obligations, including being on call for emergencies.

It’s not clear yet how it’s going to get worked out, she said, and in the meantime, some patients may face tough choices.

One 63-year-old patient, who asked to remain anonymous, said her orthopedic specialists are in one network, and her dermatology specialists in another.

“How do I choose?” she asked. “I think I’m pretty informed, but I had no clue how limited these networks are.”

Like Marcus, Polyclinic’s Corgiat worries that people won’t do their homework. “Our priority is to tell people: ‘You need to look at those networks before you choose.’ ”

Regulators watching

The narrow networks have also drawn scrutiny from regulators.

Washington Insurance Commissioner Mike Kreidler’s office initially rejected five of the nine insurers that applied to sell plans inside the exchange. One of them, Coordinated Care, was initially rejected largely because its provider network was deemed “inadequate.”

Among the insurance commissioner’s concerns was that Coordinated Care’s network did not include a pediatric hospital or a Level 1 burn unit (available only at Harborview).

But when the company appealed its rejection, an administrative-law judge ruled against the Office of the Insurance Commissioner, ordering regulators to help the company qualify. The board of the , which operates Healthplanfinder, also urged Kreidler’s office to negotiate.

The company’s plans were approved.

During Coordinated Care’s appeals hearing, company officials testified they felt confident their provider network would be sufficient. On the rare occasion when a patient needs care not available from a network provider, the company said it would cover costs without additional financial burden for the patient.

Coordinated Care CEO Dr. Jay Fathi said the company would use “single-case agreements,” which he likened to an invoice or a bill. The hospital sends the bill to the insurer, who pays it, a system he said functions “fairly smoothly.”

Children’s officials say such agreements are quite rare and are generally limited to patients who are out of network because they live outside the local area. Resorting to single-case agreements, they said, would likely delay care for patients.

But neither Washington nor federal law specifies that insurers include certain hospitals or providers. Instead, the laws look at network adequacy this way: Does a plan include enough providers, close enough to most customers that they can get the promised services in a reasonable time within a reasonable distance?

Kreidler has begun the process of changing the to give his office more control over provider networks.

In a broader way, tensions exist with networks because insurers have long seen restricting the list of providers as a way to cut costs. But such moves in the past prompted backlashes and a spate of horror stories.

Since then, few insurers have felt empowered to kick out more expensive major providers, said David Dranove, a Northwestern University professor who specializes in health-industry management issues.

But now, given that the Affordable Care Act relies on competition and market forces — and prevents insurers from excluding the sick — insurers have returned to networks as a way to keep premiums down.

“I think narrow networks are a good thing,” Dranove said.

But he added a cautionary note: “If you’re going to rely on market forces, you’d better have well-informed consumers — and that’s where we have fallen short.”

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Group Health Omits Abortion Coverage In Plans Sold On Washington Exchange

Carol M. Ostrom, The Seattle Times — Thu, 29 Aug 2013 14:26:00 +0000

This story was produced in partnership with

Group Health Cooperative will not cover abortion in its individual health-insurance plans being offered through the Washington state marketplace put in place by the Affordable Care Act, but says women who buy them will be able to access the service without paying more.

Group Health said it made the decision not to include the coverage because of murky regulations about how it would have to account for federal money in plans that offered abortion.

But the HMO (health-maintenance organization) has long supported women’s reproductive options, officials said, and so it will provide access.

Group Health’s workaround did not satisfy abortion-rights and women’s-rights groups, who reacted angrily to the decision not to cover abortion.

“Group Health asserts that abortion care will be made available to patients in Group Health clinics, but the lack of coverage in the plan creates confusion and presents a barrier to access, while showing an alarming disregard for women,” NARAL Pro-Choice Washington, Legal Voice and Planned Parenthood Votes Northwest said in a statement.

Group Health said it made the decision earlier this year in the face of confusing regulations about how insurers should handle abortion premiums and costs.

The Affordable Care Act requires insurers that cover elective abortion to segregate premiums and expenditures because federal law bars abortion services from being funded by the federal premium subsidies for plans offered through state marketplaces known as exchanges.

“At the time Group Health filed our products, we lacked further regulatory guidance,” Group Health said in a statement. “Group Health determined that in order to ensure full compliance with all requirements, it was advisable to not include pregnancy termination services in our individual products offered through the exchange for 2014.”

Of those plans that have passed muster with state insurance officials, only Group Health’s did not include abortion coverage.

At least 31 plans will be sold inside the exchange, including Group Health’s four, and other companies are now appealing rejections.

BridgeSpan Health Company, Premera Blue Cross and its subsidiary, Lifewise Health Plan of Washington, all said their plans offered abortion coverage, with the exception of eight Premera plans that are among BlueCross/Blue Shield Association multistate plans forbidden by federal law to include abortion coverage.

Stephanie Marquis, spokeswoman for the state Office of the Insurance Commissioner, said revisions flew back and forth earlier this year over Group Health’s plans for the exchange.

“Unfortunately, they made the change to take that benefit away from women, and we can’t require them to include it,” she said. “It’s an unfortunate decision for consumers.”

Group Health spokesman Ed Boyle said women who buy plans in the exchange may still access abortions services because Group Health is not only an insurer but a medical provider.

Although women who buy those plans and seek abortions won’t be covered by their insurance, Boyle said, they will not be at risk financially: “In 2014 our members who enroll through the exchange can be assured they will have access to pregnancy termination services through Group Health medical centers, with no greater financial burden than as if this was a covered benefit,” Boyle said.

Boyle said now that federal and state regulators have clarified rules regarding federal subsidies, Group Health intends to add the benefits to plans sold through the exchange in 2015, and is committed to “providing women access to the full spectrum of reproductive health services that are safe, affordable and accessible.”

Women’s-rights groups said the HMO’s decision was “inconsistent with Group Health’s own record on reproductive rights,” which has been twice affirmed by leadership and consumer members of the consumer-governed cooperative, the groups said.

Rachel Berkson, executive director of NARAL, said it was “particularly galling to see one of the most progressive, pro-women health-care providers in our state placing limits on abortion coverage.”

It’s not clear there will be limits. But Lisa Stone, executive director of Legal Voice, said she was worried that without coverage specified in the policies, women might face administrative burdens or, if they need inpatient care in a non-Group Health hospital, additional charges.

This is the kind of issue anticipated by backers of the Reproductive Parity Act (RPA), a bill that failed to gain approval in the Legislature this year. The bill would have ensured abortion coverage after the federal law took effect. Late in the session, despite backing from both sides of the aisle, Senate Health Care Committee Chairwoman Randi Becker, R-Eatonville, refused to schedule a vote.

Said Elaine Rose, CEO of Planned Parenthood Votes Northwest: “The need for the RPA has never been more apparent. Women can’t trust insurance carriers to protect all of their pregnancy options.”

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