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News & Politics News & Politics

New Affordable Care US health plans will exclude top hospitals

Posted by on Dec. 9, 2013 at 8:36 AM
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1 mom liked this

Americans who are buying insurance plans over online exchanges, under what is known as Obamacare, will have limited access to some of the nation’s leading hospitals, including two world-renowned cancer centres.

Amid a drive by insurers to limit costs, the majority of insurance plans being sold on the new healthcare exchanges in New York, Texas, and California, for example, will not offer patients’ access to Memorial Sloan Kettering in Manhattan or MD Anderson Cancer Center in Houston, two top cancer centres, or Cedars-Sinai in Los Angeles, one of the top research and teaching hospitals in the country.

Experts say the move by insurers to limit consumers’ choices and steer them away from hospitals that are considered too expensive, or even “inefficient”, reflects the new competitive landscape in the insurance industry since the passage of the Affordable Care Act, Barack Obama’s 2010 healthcare law.

It could become another source of political controversy for the Obama administration next year, when the plans take effect. Frustrated consumers could then begin to realise what is not always evident when buying a product as complicated as healthcare insurance: that their new plans do not cover many facilities or doctors “in network”. In other words, the facilities and doctors are not among the list of approved providers in a certain plan.

Under some US health insurance plans, consumers can elect to visit medical facilities that are “out of network”, but they would probably incur high out of pocket costs and may need referrals to prove that such care is medically necessary.

The development is worrying some hospital administrators who see the change as an unintended consequence of the ACA.

“We’re very concerned. [Insurers] know patients that are sick come to places like ours. What this is trying to do is redirect those patients elsewhere, but there is a reason why they come here. These patients need what it is that we are capable of providing,” says Thomas Priselac, president and chief executive officer of Cedars-Sinai Health System in California.

One of the biggest goals of “Obamacare” was to make subsidised healthcare plans that are being sold on the new exchanges as affordable as possible, while also mandating that certain benefits, like maternity care, were covered and that people with pre-existing medical conditions could not be denied access.

Amid these new regulatory restrictions, says Tim Jost, a health policy expert, insurance companies have had to come up with new ways to cut the cost of their products. In this new era, limiting the availability of certain facilities that are seen as too expensive – in part because they may attract the sickest patients or offer the most cutting edge medical care – is seen as the best way to control costs.

“It’s like buying a Mercedes-Benz or a Chevy. You have to decide whether you want to pay for the highest product out there, which is probably pretty good quality, or the less expensive product,” Mr Jost says. “Everyone is in favour of competition until they see what it looks like. Then they think, maybe it’s better for someone else just to pay for the whole thing.”


Kathleen Harrington, who heads government relations for the Mayo Clinic in Minnesota, says that access to the famous clinic was initially limited in the Rochester, Minnesota area until officials at the healthcare exchange board in the state encouraged insurers to expand their network options.

While the Mayo Clinic will now be available on seven different plans offered by two different insurance carriers in Rochester, Ms Harrington says the long-term concern for the hospital is that intense focus on bringing down costs will hurt “centres of excellence” like Mayo that attract the most complicated medical cases in the country.

“I don’t think there is any doubt that a significant portion of the Mayo base are very sick patients. You don’t come here for primary care. We do treat the sickest of the sick. We do experimental treatment. This is where you come for innovative treatments for life threatening illnesses,” she says.

“If healthcare, the full spectrum from primary to top speciality care, becomes commoditised, it becomes a concern for the American healthcare system,” she adds.

When the Obama administration was asked whether the new healthcare exchanges were offering adequate network options to new consumers, a spokeswoman for the Department of Health and Human Services (HHS) emphasised that the new exchanges would “vastly increase” the access to medical providers to millions of uninsured Americans.

“Decisions about which private health insurance plans cover which doctors is a decision currently made by insurers and providers and will continue that way,” said an HHS spokeswoman.

The top lobby group for US health insurance plans, America’s Health Insurance Plans, said the new healthcare law brought “new costs” to the industry and that selecting hospitals and physicians that meet “quality standards” was one way of making health plans more affordable for consumers.

But Mr Priselac at Cedars-Sinai in Los Angeles says the creation of ever more narrow provider networks by insurers is being driven by price alone, and not by quality. He says the hospitals that are being excluded are leaders in innovation, which saves billions of dollars for the healthcare system in the long run.

“There is confusion between price and efficiency,” he says. “The major teaching and research hospitals are more expensive not because they are inefficient but because of what they do.”

by on Dec. 9, 2013 at 8:36 AM
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4kidz916
by Gold Member on Dec. 9, 2013 at 10:32 AM
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So we're back to only the rich and powerful getting the best of treatments.  And I thought it was said that the Republicans hated the poor and were trying to keep the lower class down.  Thanks Obamacare.

PrimmednPunked
by Silver Member on Dec. 9, 2013 at 11:13 AM
Note here this is being driven by the insurers to cut costs. Now, who re still believes that insurance companies are about taking care of people?
vic270
by Vic on Dec. 9, 2013 at 11:19 AM

obama has insured the insurance companies that over the next ten years that they will not loose any money [up to 1 trillion dollars] this was on the news saturday. i don't have the link but you can look it up.

Billiejeens
by Ruby Member on Dec. 9, 2013 at 11:25 AM
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 I don't know anyone that ignorant, do you?

Neither Government or Insurance Companies take care of people.

Health Care providers take care of people.

Dang this is the easy stuff - it gets harder from here.

Quoting PrimmednPunked: Note here this is being driven by the insurers to cut costs. Now, who re still believes that insurance companies are about taking care of people?

 

4kidz916
by Gold Member on Dec. 9, 2013 at 11:35 AM

Insurance companies have never been about taking care of people, they're about profit.  This ACA has just given them even more freedom to screw the American people. 

Quoting PrimmednPunked: Note here this is being driven by the insurers to cut costs. Now, who re still believes that insurance companies are about taking care of people?


jobseeker
by Bronze Member on Dec. 9, 2013 at 12:07 PM
3 moms liked this

Providers already give big discounts to insurance companies to be a preferred provder.  Hospitals provide care to Medicare and medicaid patients for a reimbursement that is less than the cost of doing business.  If a hospital or provider is not paid for thier service at a market rate and are not allowed to even brake even much less at a rate that allows for a small profit, how long can they keep their doors open?

Make no mistakes.  This is a vicious cycle.  Insurance companies are unable to agree with providers and facilities to make reimbursements that allow for a profit, the providers will not agree to be providers, and the patient will be the ultimate loser.

Before you argue about the ethics of medical providers making a profit, let me remind you that these Doctors have studied for years and are required to maintain an equipped office and pay a staff and maintain malpractice insurance all before they take a dime home.  Hospitals have the expense of maintaining facilities, state of the art equipment, insurance, and staffs.  Why is it okay for professional athletes and entertainers to take home millions, but the doctor who cares for your family is supposed to give it away? 

Quoting PrimmednPunked: Note here this is being driven by the insurers to cut costs. Now, who re still believes that insurance companies are about taking care of people?


SallyMJ
by Ruby Member on Dec. 9, 2013 at 3:28 PM
2 moms liked this

So THAT'S how we get "quality", "affordable" health care in Obama's American -- just leave off the best hospitals and the best doctors!

If you want THOSE, you'll just have to pay more.

So says Zeke Emanuel, bioethicist and chief architect of Obamacare.

Who cares what Obama promised?

DSamuels
by Gold Member on Dec. 9, 2013 at 4:44 PM
1 mom liked this

I was reading also that 70% of Cali doctors are refusing to enroll in the exchanges. That means people in Cali will have very little choice in doctors and wait times will probably be very long. Adding many patients and losing 2/3 of doctors is a recipe for disaster.

SallyMJ
by Ruby Member on Dec. 9, 2013 at 5:40 PM

Those in Kaiser will be OK, because all those doctors are partners in the medical group, and their payment won't decrease. I think that may be the majority of the 30%.

Quoting DSamuels:

I was reading also that 70% of Cali doctors are refusing to enroll in the exchanges. That means people in Cali will have very little choice in doctors and wait times will probably be very long. Adding many patients and losing 2/3 of doctors is a recipe for disaster.


JoJoBean8
by Silver Member on Dec. 9, 2013 at 7:45 PM

Lovely

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