Communities balance access issues

Clearly the worst effect of change under the Affordable Care Act (ACA) is the initial disruption it can cause for patients. Payers and providers are acutely aware of the issue, even if they don’t always agree about how to solve it.

In Washington, Seattle Children’s Hospital has been publicly at odds with insurers over the trend toward narrow networks. 

The disagreements have been going on since October 2013. Seattle Children’s balked when it noticed that half of the insurance carriers on the state’s exchange did not include the hospital in their networks. 

“We were concerned that families did not know the plans they were buying did not include care for their children at Seattle Children’s,” says Sandy Melzer, MD, senior vice president and chief strategy officer for the hospital.

Children’s filed a suit against the state Office of the Insurance Commissioner (OIC), citing failure to ensure adequate network coverage in the exchange plans. Separately, Seattle Children’s also filed an administrative appeal asking OIC to kick three insurers out of the exchange-Coordinated Care Corporation, Bridgespan Health Company and Premera Blue Cross-that had been previously approved as Qualified Health Plans. The complaints are still pending.

The insurers have remained on the exchange, and consumers have enrolled in their plans.

Care continuity

In January, Dr. Melzer says, the specialty hospital treated 125 patients who didn’t have in-network coverage and vowed to forgive the families’ additional costs. He says the reason why the hospital went ahead with treatment was for the sake of care continuity and because Seattle Children’s offers unique services that he believes the patients’ in-network providers don’t offer.

Children’s also filed paperwork with the plans asking for exceptions. It was certainly a reasonable request since even President Obama had asked health insurers to be flexible and allow patients to continue treatment at in-network levels during the ACA transition. Dr. Melzer says only 21 out of some 200 coverage requests had been answered by the end of January-and eight were denials. 

“Plans have been very uncommunicative with us regarding how they were going to handle patients who were referred to us or what the process would be for a patient request to be seen by us, not in-network,” Dr. Melzer says. 

Some patients were in the process of treatment on January 1 when their new coverage began, and some had been specifically referred to Seattle Children’s after January 1 for specialized care.

For certain specialty services, such as transplant and pediatric rheumatology, for example, the hospital is the sole provider not just in the state but in the region, according to Dr. Melzer.

“We’re the only full-service children’s hospital in a four-state area,” he says. “There are very unique services at the hospital that are simply not available at any of the hospitals that the plans have said are in-network.”

Payer priority

Premera Blue Cross was particularly singled out by the hospital. It’s the largest individual insurer in the state-claiming 60% of the exchange enrollments so far-and covers 1.8 million people. But the plan says the hospital is only telling one side of the story.

“One of our priorities is making sure our members have access to unique services like the ones at Children’s,” says Eric Earling, director of corporate communications for Premera. “Unfortunately the information that Children’s recently released gives a really incorrect impression about how our members are able to access those services.”

While Children’s is not in the exchange-plan network for Premera, access is still available, Earling says.

For unique services at the hospital, Premera offers its exchange-plan members the in-network benefit levels, paying 80% of the costs. For all other services, members pay out-of-network rates, at 50% of the costs. Either way, patients still have access, and Children’s still receives reimbursement, Earling says.

But there’s also the issue of the appeals. According to Dr. Melzer, only 21 appeals for in-network coverage had been answered by Premera-a statement Earling disputes.

“As of January 29, we received approximately 190 requests for members on metallic plans looking to access unique services at Children’s-or what they believe to be unique services,” he says. “We approved 70% of those requests, so the members have access at the in-network rate.”

And he says, the requests are processed in five days with members receiving notification of denials and lists of alternate in-network providers that Premera has proactively confirmed can manage the patient.

“We looked at our options, understanding the upward pressure ACA puts on rates for coverage,” Earling says. “If you look at the affordability for Children’s non-unique services-services that can be provided at other facilities in the area-they are simply not affordable.”

Premera ran a data analysis of distinctive services offered by Children’s against its claims experience and found only 12% of the member visits to the hospital were for unique services, and the other 88% were not. And utilization wasn’t the only factor.

“Children’s costs 60% more than the statewide network for non-unique services,” Earling says. “If you drill down even further to inpatient costs for non-unique services, Children’s costs 100% more.”

He says Premera’s data analysis was normalized for the complexity and severity of the cases.

“Our data points acknowledge and call that out many times: They are seeing a different kind of patient,” he says.

But Dr. Melzer doesn’t see it that way. He says the pediatric patients at Seattle Children’s have underlying medical conditions that aren’t figured in.  

“These comparisons from what we can tell are not apples-to-oranges but apples-to-orangutans,” Dr. Melzer says. 

Earling says some providers have tried to portray the network selection as an access issue, but it isn’t because Premera members have access to unique services at an in-network level. 

“The issue is the cost at Children’s for non-unique services and the impact that would have on the affordability of health plans.”