Shrinking Health Care Networks on Exchanges, Expensive out of Network Costs, Local Hospitals Not Passing Quality Standards, Problems with Post Hospital Costs for Medicare, and more

While everyone is focusing on whether or not is going to work,  there are other significant issues about access that must be addressed.   A critical issues is who is in the networks offered in the insurance exchange products.

What is at issue in these network restrictions is cost–and consumers could unknowingly be getting the short end of the stick.  As reported in The Seattle Times: 

“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.”  (emphasis mine).

Be sure and read the following article: some networks don’t include Swedish, but do include Virginia Mason.  But Virginia Mason does not deliver babies.  Some networks exclude UW Medical Center, which is one thing, but they also exclude Harborview, the region’s major trauma center. Life threatening trauma cases are always taken there first because they have the specialty care, staff and services to handle severe traumatic cases, such as accidents or injuries. That is how EMT medical teams are trained–take the patient to the closest trauma center hospital.

I know. My son was taken to Harborview when he was in what turned out to be fatal car accident.  While 13, even Children’s could not have provided the trauma care he needed with a head injury.

Right now, Children’s Hospital and Medical Center is not in many plans while this institution has the expertise that many others hospitals don’t.  Yes, Children’s  may seem expensive, but they do know what they are doing when it counts.

While hospitals do compete, they often cede to each other specialty care.  It would simply be too expensive for each hospital to have its very own specialized care–such as severe trauma, pediatric care, cancer care.  Having those specialized services at all or many hospitals means they would have neither the expertise to provide excellent care nor, to be crass, the ‘volume’ of cases they would need to cover the costs of that care.  As an example, the first heart transplant patient at UW was a Group Health patient–it was better and cheaper for Group Health to pay for care at UW that had a heart transplant program than for Group Health to develop and pay for their own program.

That is why networks matter, especially if people have to pay for out of network care themselves.  Read this article–and make sure the Insurance Commissioner in our state and others, is looking into this key issue:

Speaking of hospitals, however, 72% of Washington state’s did not pass federal quality tests:

“Thirty-four hospitals in Washington state, including six in Seattle, will have their Medicare payments cut based on federal quality measures that are supposed to control costs and improve care.”

We have all heard stories of insurance cancellations in the individual insurance market.  It might be worth reading this story that digs into the issue a little more:

Finally,  the following article has a really interesting chart with it about post-hospital costs for Medicare.  It includes a state by state comparison of post-hospital costs for rehab care. Sometimes I think there is no one minding the store on home health care and rehab costs. That is the one thing the current administration seems to be doing.   There is much more to this story coming up about the financial chaos for patients that is happening  because of a new ‘ruling/category of care’ hospitals have developed to avoid being fined.  More on that soon.  In the meantime, check out the differences in costs per state.

Ironically, the costs were driven up by the Reagan administration’s efforts to control hospital costs by having new payment reform called: DRG’s (Diagnostically Related Groups), that were designed to get patients out of hospitals faster and reduce the cost of hospital care.  The cost of that care has to go somewhere.  I am not a health care economist.  But, until we get a rationale system of care, which we are slouching toward–health care costs are like a balloon–push it here, it pokes out there.

There are many, many good things that are happening with the ACA re: payment reform being one of them that is not being written about widely…. but I will say again now, as I wrote in my first published op-ed in the Puget Sound Business Journal in Feb. 1991–“Without a Plan, Health Care Will Remain a Mess.”  

I’ll have to scan the hard copy to share it.

Yes, the implementation of the ACA is messy. But so is health care.  And as I am fond of saying–if this were easy someone would have done it before.  It is time to work together to make this work than take pot shots that anyone can do.   It is harder to build than knock down.

Kathleen O’Connor (c) 12/2/13




About Kathleen

Kathleen O’Connor: 30+ year health care consumer advocate, non-profit executive and author. For more information about Kathleen, please see "About" on the main content bar above.
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