Tiered medical care pits choices against costs - LivewellNebraska.com
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Tiered medical care pits choices against costs

Choose a certain hospital or a certain doctor in Omaha, and you'll pay more.

Choose another, and you'll pay less.

A sampling of the hospital networks for policies on the Affordable Care Act marketplace illustrate the trend toward narrower choices of physicians and hospitals. Different policies offered by the same insurer may have different networks.

For detailed lists of doctors, clinics and hospitals, see HealthCare.gov or each insurer's website.

Examples from the Affordable Care Act marketplace:

» Blue Cross Blue Shield SelectBlue (Omaha area)

Tier I: Nebraska Health Partners, Bellevue Medical Center, Methodist Health System, Children's Hospital & Medical Center, Fremont Area Medical Center.

Tier II: Alegent Creighton Health affiliates, Community Memorial Hospital in Missouri Valley, Iowa; Mercy Hospital in Council Bluffs; Midlands Hospital in Papillion.

» CoOportunity Health Preferred

Nebraska: Midlands Choice network, including all hospitals.

Iowa, Tier I: Genesis Health System, Mercy-Cedar Rapids, Mercy Health Network, University of Iowa Health Care.

Tier II: Other hospitals in the Midlands Choice Premier network.

» Coventry Bronze $10 Copay POS MIPPA: Methodist Health Partners, Methodist Women's Hospital, Children's Hospital, Jennie Edmundson Hospital.

Coventry Bronze HMO $10 Copay: Alegent Creighton Health and affiliates, St. Elizabeth Medical Center.

» Health Alliance Midwest Guide HMO

Alegent Creighton Health and affiliates, St. Elizabeth Medical Center.

That choice is increasingly common and financially significant as insurance companies draw lines between medical care providers based in part on their willingness to charge less in return for the chance at a higher volume of patients.

That makes it important for you to know whether your doctor, clinic and hospital are part of your insurance policy's network. If not, you can brace yourself for higher costs, consider switching doctors to save money or change insurance policies or companies to match your medical preferences.

Pricing differences that are hitting individual and small-business insurance today likely will work into large employer group coverage within a few years, affecting virtually everyone.

The pressure to reduce medical costs predates the Affordable Care Act, but provisions of the law, also known as Obamacare, accentuate the importance of cost and, eventually, quality in choosing health care professionals and the insurance that pays for them.

Health maintenance organizations, which faded from Nebraska and Iowa over the past decade, are back as options on HealthCare.gov, the Obamacare website. HMOs pay no benefits to out-of-network health care providers, meaning you'd be responsible for the entire bill.

But the Affordable Care Act requires networks, no matter how narrow, to provide adequate care in all of the essential benefits covered by the insurance policies. The law caps consumers' annual out-of-pocket costs within plan networks but doesn't protect them from additional bills from outside providers.

For now, options still include some broad network plans with nearly uniform prices for medical care at virtually all hospitals and doctors in the two states. But you also can choose narrow network plans, exclusive provider organizations and multitiered plans, all of them dividing up hospitals and doctors by cost.

“You're trading off having a lot of choice with having a lower expense,” said Susan Millerick, a spokeswoman for Aetna, parent company of Coventry Health.

Omahans' SelectBlue policies of Blue Cross Blue Shield of Nebraska, for example, pay more at Alegent Creighton Health's Omaha-area hospitals, called “Tier II,” than they do for the same treatment at Nebraska Health Partners, Methodist Health System and Children's Hospital, called “Tier I.”

The difference, which began last year, is not small.

For one Obamacare-qualified Blue Cross individual policy, the annual deductible is $3,500 for Tier I care and $7,000 for Tier II care. Some plans charge $20 for a Tier I office visit and $40 for a Tier II visit.

Discounts for services between Tier I and II also are significant, said Blue Cross, the state's largest health insurer.

CoOportunity Health, a new insurance cooperative, adopted the Midlands Choice broad network — meaning all hospitals and nearly all doctors — in Nebraska. In Iowa, CoOportunity offers a broad network, an HMO and an exclusive provider organization with a restricted network.

Coventry and Health Alliance Midwest, the other insurers offering policies in Nebraska on the Obamacare marketplace, also have in-network and out-of-network divisions, including some HMOs.

In return for getting more patients, Millerick said, doctors and hospitals within a network “give us a better discount. We're able to pass that along in the premium.”

“For the first time, my colleagues are going to be cost-conscious,” said Dr. Gamini Soori, an Omaha cancer specialist and president of an independent physicians group that set up a new health care network for Coventry policies in Douglas, Sarpy and Pottawattamie Counties.

Beyond Obamacare's initial goal of insuring all Americans, the law aims at both cost and quality.

“That's the holy grail,” said CoOportunity co-founder Cliff Gold. “If you can control quality and cost, now you have the ability to create a more affordable, high-quality health care system. That's a long ways from where we are today.”

Blue Cross' discount strategy divides Omaha hospital competitors, with Alegent Creighton on one side and Methodist and the Nebraska Medical Center, which have an informal partnership, on the other.

Alegent Creighton and its health care network, called UniNet, ended up on Blue Cross' more-expensive Tier II list because they declined to discount services and instead offered a shared-savings plan to Blue Cross.

A shared-savings plan would split overall cost savings between Alegent and Blue Cross created by managing patients so they would need less treatment, a strategy known as reducing utilization of medical care.

Lee Handke, a Blue Cross vice president, said Alegent Creighton's cost for services was more expensive and Blue Cross believes “they would not be able to manage out enough utilization to make their overall cost of care less expensive.”

The discounts by the other hospitals mean lower costs for the same services under old policies, Handke said, a cost reduction in line with the law's goals. Large-employer groups also are signing up for the two-tier system because of the lower costs.

Blue Cross isn't planning to start an HMO, he said. The two-tier approach reached the prices Blue Cross wanted, reducing costs between 10 and 20 percent, Handke said.

Ann Oasan, executive director of UniNet, said she believes shared savings efforts are more effective at achieving high-quality, lower-cost care.

“I don't think you can do that by just cutting your rates a little bit,” she said. “It's a way to work together to have the same goal, trying to lower the cost of health care. That was not what they (Blue Cross) were looking for. They just wanted a flat discount. We weren't interested, really, in cutting our rates.”

It's too early to say whether the higher costs will mean fewer patients, she said. “Will they move to a new provider for $10? I don't know if they will or not.”

Methodist Hospital agreed to the discounts Blue Cross wanted, said Mark A. Burmester, vice president for strategic planning and business development, so patients would have full access to its health system.

“There is a distinct advantage for insured members to utilize Tier I providers because it will save them out-of-pocket dollars toward their health care,” Burmester said. “If you use Tier II providers, there are higher copayments, higher deductibles and less of a discount for services.”

At the same time, Methodist is working to control utilization by keeping people healthier so they use fewer medical services, said Brian Smullin, Methodist's managed care director.

“We're focused on the total cost of care. That's going to be our mantra for decades to come,” he said. “That's what the Affordable Care Act is trying to address, ultimately — how we're going to reduce our nation's health care expenditures, how we get ahold of the escalation.”

Doctors, including those who are independent and don't work for hospitals, should have a say in how that's done, said Dr. Soori, the cancer specialist. He is founder of the Midwest Independent Physicians Practice Association and recruited about 950 physicians for the network with Coventry. That's about one-third of the doctors in the Omaha area.

For the MIPPA-Coventry plans, Alegent Creighton and Methodist are “in-network” on separate policies and Nebraska Medical Center is “out of network” but available to policyholders at higher prices.

Soori said doctors in the network agreed to reduce rates to keep premiums down. “The doctors are taking a financial risk. If we didn't do that, the premiums would be much higher.”

Even Midlands Choice, a popular broad network formed in 1993 by hospitals in Nebraska and western Iowa, is considering tiered pricing options, said Thomas E. Press, president and CEO. But it's uncertain how successful the narrow networks will be if they focus only on price.

“The broad-access networks have usually won the battle,” he said. Few markets in Nebraska and Iowa have more than two or three hospital choices, so discounting services may not attract enough new business to make up for the discounts and keep medical care providers financially healthy.

The long-term difference between health systems will be the efficiency and effectiveness of their care, Press said.

“The more they're willing and able to combine the delivery and financing and management of health care into one single package, the more consumers and employers will be able to evaluate how effective those plans are,” he said.

Methodist's Burmester said the hospital participated in the MIPPA-Coventry plan because some of its affiliated doctors are members of the independent physicians group and wanted to join the network.

Today, making a choice of networks is facing mostly individual policyholders. Over the next few years, he said, people covered through group policies at work will have to make the same decisions.

“It's really important ... that they really not only obviously look at the premium costs but also the network of providers,” Burmester said. “Across the country, you're seeing these new health plan offerings, narrow networks, that are more appealing to the consumer, to the employer, because they do offer a more affordable price, less out-of-pocket expenses for families and those who are individually shopping on the exchange.”

Gold, the CoOportunity co-founder, said provider networks are one of the few ways that insurance policies can set themselves apart under the Affordable Care Act. The law requires the same coverages, and insurers can't vary prices according to someone's medical history.

That sets the stage for HMOs to regain customers in Nebraska and Iowa by offering lower prices, he said, but it's too early to tell whether consumers will be willing to accept narrower choice in return for savings.

The next step, Gold said, will be for health insurers to use solid quality data to encourage consumers to use the highest-quality doctors and hospitals. One hospital might be the best for heart care, for example, while another is best for cancer. Insurance benefits would steer customers toward the best.

But that's a decade or more away, he said. In the meantime, narrow networks probably offer the lowest overall insurance cost. CoOportunity may introduce an HMO or an exclusive provider organization, or both, in Nebraska next year.

“You're asking people, if you're willing to trade price for access, there are cheaper alternatives for you,” Gold said. “It provides more choice in the market and it forces consumers to get more involved in their choice of health plan.”

Provisions of the Affordable Care Act will require far-reaching changes in health care, including hospitals and doctors accepting some of the financial risk for the outcomes of the medical care they provide, Gold said.

In the past, many people with serious health problems often were stuck with the same health insurance policies even if costs went up or quality suffered. Now consumers can switch plans and care providers easily if they become dissatisfied.

“Like it or not, the ACA is the most fundamental sea-change in health care in our lifetime,” Gold said, and not all insurance and medical organizations will succeed. “There will be winners and losers.”

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