qotd: Choose a high ranked hospital and lose your choice of plans

Robert Wood Johnson Foundation
February 6, 2016
Most Regionally Ranked Hospitals Stay In-Network with Marketplace Plans,
But Participation Declines
By Katherine Hempstead, PhD, MA

Looking at network participation by state, nearly all highly ranked
regional hospitals were in-network with at least one marketplace plan in
both 2015 and 2016.

Key Findings

* Network participation decreases significantly, however, as more than
half of hospitals reduce the number of networks in which they
participate between 2015 and 2016.

* The percent of hospitals in-network with only one marketplace plan
increased from 7 percent in 2015 to 20 percent in 2016.

* Network participation declined more in metro areas.

* Customers loyal to a particular hospital can in most cases still find
a marketplace plan that includes it, but choices are narrowed in 2016
relative to 2015; plans with these hospitals may be more expensive.

Conclusion

Many consumers returning to the marketplace in 2016 may find that their
choices have changed in ways that limit their access to certain
providers. Yet it is still the case that almost all of these highly
rated hospitals are in-network with at least one marketplace plan.

http://www.rwjf.org/en/library/research/2016/02/most-regionally-ranked-hospitals-stay-in-network-with-marketplac.html

Brief (15 pages, mostly tables):
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf426368

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Comment by Don McCanne

A well-functioning health care system should be designed such that
patients who would specifically benefit from the services of a highly
ranked regional hospital should be assured of access to that hospital.
Instead, we have a health care system that ignores the primacy of the
patient, and, in this instance, places the highest priority on the
business relationship between the hospital and the insurer. As a result,
far too many insured patients do not have coverage for highly ranked
regional hospitals.

In many communities, only one insurer includes the highly ranked
hospital. Thus the patient must make a choice between buying that plan,
which is usually more expensive, or buying a competing plan which
otherwise may be more suitable because of the many other variables
between plans. This is getting worse since participation of highly
ranked hospitals in multiple plan networks is declining.

A far better system would provide the patient with a choice of primary
care services wherein guidance can be provided to ensure access to the
most appropriate facilities and specialized services in the community.
To inject into the consideration private insurer restrictions on what
services and facilities can be used is the epitome of poor health
planning. Yet this is the system that many politicians and policy wonks
insist that we must protect, limiting changes to incremental tweaks.

What incremental change would fix this? Should we require all insurers
to cover all health care professionals and all facilities? If so, then
how would an insurer have any power to negotiate lower rates with a
provider that must be included? Instead of negotiating individually with
providers should we set standard rates, as Medicare does? If so, then
why would we continue to use a wasteful, fragmented market of private
plans and public programs when one public entity could administer the
system much more efficiently?

These are not examples of incremental steps that preserve our
multi-payer system. This is one step that replaces our dysfunctional
financing system with a single payer national health program. Our
financing system is beyond repair, and incremental additions won't
change that. It's the fundamentally flawed financing infrastructure that
needs to be replaced.