Georgia Society, American College of Surgeons: October 2013

BY CARRIE TEEGARDIN - THE ATLANTA JOURNAL-CONSTITUTION

The Piedmont, Emory and WellStar health systems, which run some of Atlanta’s marquee hospitals, will not be available under many of the health plans being sold on the new Health Insurance Marketplace.
News coverage of the insurance exchanges has focused on bad software and big crowds on the federal sites. But the exchanges have other, more far-reaching limitations: the official networks of hospitals and doctors are smaller than many shoppers might expect.

Wellstar Health, which has five hospitals in Cobb, Paulding and Douglas counties, including Kennestone Hospital, is not in network for many competitively priced plans. But some providers, like Humana, offer two types of plans. Plans that offer a larger network of doctors and include most hospitals in the state are available but are also more expensive.
For example, statewide the new Blue Cross and Blue Shield of Georgia network for the Obamacare plans contains about half as many doctors and slightly more than half as many hospitals as Blue Cross’ overall commercial network. The insurer, the state’s largest, said networks can change and more providers may sign on in the coming months.

“These networks are going to be a surprise to many people with coverage now,” said Bill Custer, a health care expert at Georgia State University. “The narrowness of these choices is going to be a concern.”

Another likely shock will be the consequences of “going out of network.” Under many of the new plans, you would have to pay 100 percent of out-of-network charges for anything other than emergency care.

The Health Insurance Marketplace is a key part of the Affordable Care Act. While the marketplace is transforming the way many Americans buy individual policies, it will have no impact on employer-sponsored health insurance or on Medicare, at least for now.

‘People need good, solid information’

Insurance companies have been hinting for months that plans on the Health Insurance Marketplace would feature “narrow” or “skinny” networks of doctors and hospitals. But only the Oct. 1 opening of the exchange enabled The Atlanta Journal-Constitution to determine just what that would mean for consumers.

The AJC found that one competitively priced plan offered by Humana will cover care only at Atlanta’s Northside Hospital and its satellite locations in Cherokee and Forsyth counties.

Blue Cross and Blue Shield doesn’t have any Emory, Piedmont or WellStar hospitals in its network for its new plans on the exchange, even though those health systems are dominant players in the Atlanta market. Blue Cross’ current commercial plans do include those hospitals in their networks. The Atlanta-area hospitals in the new Blue Cross plans are those operated by Northside, Gwinnett Medical, DeKalb Medical, Grady Memorial, Eastside Medical and Children’s Healthcare of Atlanta.

Anyone can shop for insurance on the marketplace, but the plans are directed at Georgians who do not get coverage at work and must buy their own insurance. The technical difficulties that bedeviled the Health Insurance Marketplace during its first 10 days kept most Georgians — and many people across the nation — from researching their options.

In addition, The Atlanta Journal-Constitution found, the Piedmont and Emory systems were initially unclear about whether they were included in a plan being sold on the exchange. Doctors also said they were having difficulty getting information about their role in the plans. Insurers and hospital executives said the networks could change at almost any time — making it even harder for consumers to make well-informed choices.

“Frankly, I can’t even tell who the provider networks are under some of the these plans,” said Jim Budzinski, the chief financial officer for the WellStar Health System, which runs five hospitals and employs hundreds of doctors in Cobb, Douglas and Paulding counties. “People need to choose based on good, solid information, and I’m not sure we’re there yet.”

‘I want the freedom to choose’

Five insurers have signed on to sell health plans on the marketplace in at least one region of Georgia. But most Georgians will have fewer than five choices, since only Blue Cross and Blue Shield is offering plans in every county in the state. Most metro Atlantans will be able to select from plans by Blue Cross, Humana and Kaiser. Alliant and Peach State are offering plans in a few counties within the Atlanta region, as well as elsewhere in the state.

The Blue Cross, Kaiser and Peach State plans on the marketplace are all “health maintenance organization” plans — better known at HMOs. That means the plans only pay for care outside of their narrow provider networks only in emergencies.

Humana is offering two types of plans. Its HMO plan is the one that offers care only at Northside Hospital’s system. But Humana is also selling a more expensive “National Preferred” plan with a large network of providers that includes most hospitals in metro Atlanta, including the Piedmont, Emory and WellStar facilities.

Georgians who have been uninsured for years may be thrilled to have access to any network of doctors and hospitals. However, those consumers who have always been insured and who will be buying their own coverage on the Health Insurance Exchange may be less than pleased with the limited networks.

“It takes away a freedom — it’s dictating,” said Lisa Paulauskis, 49, of Marietta. She and her husband, who have grown children, retired early and now buy their own health plan. They plan to shop on the marketplace to see what’s available.

“I have always gotten the PPO — the preferred provider,” Paulauskis said. “If I had to pay a little more, I would be able to continue with doctors my kids knew and continue with doctors I knew.”

Paulauskis said she and her husband are in good health, but she will still shop for a plan that preserves her ability to see her current doctors, mostly affiliated with WellStar, while also allowing her to go out of network if she finds it necessary. She said she knows people who have traveled across the country to get the best care for serious conditions.

“I want the freedom to choose,” she said.

Consumers who buy their own health plans can also shop outside of the marketplace, where there will be more choices. The only way to obtain a tax credit to help pay for a plan, however, is on the exchange.

‘A jump start of a trend’

The limited hospital and physician choices present a dramatic shift for many consumers who have grown accustomed to plans that included broad “preferred provider” networks that offered access to a wide range of doctors and hospitals — and also paid at least part of the bill for out-of-network care. But it’s something that all consumers may face in the coming years, whether they are shopping on the Obamacare insurance exchange or getting coverage at work.

“This is a jump start of a trend that has been continuing,” said Custer, of Georgia State. “The range of choices consumers faced under any health insurance plan has been becoming more restrictive, and the trade-off is that by having a more restrictive choice, you are supposed to get more integrated care. There is supposed to be both quality and cost improvement as a result of that. That’s the trade-off we have been facing as a nation. It isn’t a trend the ACA started, but it clearly is speeding it up.”

Custer said large employers are also starting to use smaller networks to reduce health care costs, and health systems are trying to position themselves as one-stop shops that focus on preventive care and high-quality results. This trend drove the Piedmont and WellStar health systems to create their own insurance company, which has begun selling plans that provide care through the doctors and hospitals in their systems.

The Piedmont-WellStar plan is not being sold on the exchange this year, but that is likely to change as the new plan and the new marketplace become more established.

The Kaiser Foundation Health Plan of Georgia is offering its well-established HMO plan on the exchange. The plan has deliberately set up a narrow network and operates that way by design, said Jim Cullinan, vice president of marketing, sales and business development for Kaiser Permanente of Georgia.

Kaiser limits its members primarily to its 450 physicians working out of 30 offices in metro Atlanta and Athens. It has contracts with Piedmont and Northside when its members need hospital care. Limiting the network, at Kaiser, is more about insuring quality than whittling down a system to achieve financial targets, Cullinan said.

‘Really wasn’t much of a negotiation’

When designing plans to sell on the Marketplace, insurers had to limit patient provider choices to keep prices low enough to attract uninsured Georgians to buy coverage, said Morgan Kendrick, the president of Blue Cross and Blue Shield of Georgia.

The law requires that all plans on the marketplace include 10 “essential benefits” covering everything from emergency and hospital care to prescription drugs, maternity, mental health and other services. The plans also have to cover preventive care, such as vaccines and cancer screenings, with no out-of-pocket costs for customers. So insurers didn’t have the option to keep prices low by skimping on benefits.

In a smaller network, the insurance company can charge lower premiums because it pays the providers less. The providers, meanwhile, benefit by receiving a reliable flow of patients from the insurer.

While consumers buying individual plans will not have access to the large network that other Blue Cross customers have, they need to understand it’s simply a smaller version of the company’s slate of qualified providers, Kendrick said.

“These doctors are all doctors that are participating in our commercial network today,” he said. “This isn’t like a subset of second-class providers. That’s not at all the case.”

Budzinski, the WellStar CFO, said some insurers didn’t offer much give-and-take when offering providers a spot on their plans in exchange for reduced payments. WellStar is currently a provider in a Humana plan and an Alliant plan being offered in just a few metro Atlanta counties.

Some insurers “never approached us and others approached us and it was almost like take it or leave it — if you want to be in the network here are the rates,” Budzinski said. “There really wasn’t much of a negotiation and there really wasn’t any real concern about who the provider network would be.”

‘From a patient perspective, I would be concerned’

The Piedmont system decided to stay on the sidelines instead of taking some of the deals on the table for the new plans on the exchange. “There was so much uncertainty around the plans themselves, as we were having discussions with insurers, that we felt the best approach right now would be to see how this progresses,” said Matt Gove, a Piedmont spokesman.

Donald Palmisano, executive director of the Medical Association of Georgia, said he wonders whether there will be enough doctors in the new, limited networks to care for the patients who opt for the plans being sold on the exchange.

“From a patient perspective, I would be concerned,” he said. “When you are getting ready to purchase a plan you want to make sure your physician is in that network.”

Those shopping on the marketplace — healthcare.gov — should see a bright blue “provider directory” link that will take them to information about the networks associated with plans they are considering. Experts cautioned consumers not to skip this step, because the network list may be one of the most important factors to study before buying a plan.

Blue Cross and Blue Shield of Georgia
Availability of Health Insurance Marketplace plans: All counties in Georgia.

Plan type: HMO

Details: Blue Cross, the state’s largest insurer, has a broad overall network to care for members who get insurance at work. The network for its new Affordable Care Act plans is more limited. Its metro Atlanta network for the new plans currently includes these hospitals and health care systems: Children’s Healthcare of Atlanta, DeKalb Medical Center, Grady Health System, Eastside Medical Center, Gwinnett Medical Center and Northside Hospital.

Kaiser Permanente of Georgia

Availability of Health Insurance Marketplace plans: 28 Georgia counties, including all of metro Atlanta.

Plan type: HMO

Details: Kaiser is a well-established health maintenance organization with 450 doctors who care exclusively for members of the Kaiser plan at its 30 medical offices in metro Atlanta and Athens. Kaiser has contracts to provide hospital care at Piedmont Hospital and Northside Hospital.

Humana

Availability of Health Insurance Marketplace plans: 83 Georgia counties, including all of metro Atlanta.

Plan types: HMO and POS.

Details: Humana, one of the nation’s largest insurers, is offering a “point of service” plan in addition to an HMO plan.

The plans are dramatically different and the HMO is not available in every county. The HMO requires members to get care within a small network of doctors and hospitals. For Atlantans, that network includes Northside Hospital and its satellites in Cherokee and Forsyth counties.

The POS plan offers a more extensive network including these hospitals and hospital systems: Atlanta Medical Center, DeKalb Medical Center, Eastside Medical Center, Emory Healthcare, Grady Health System, Gwinnett Medical Center, North Fulton Hospital, Northside Hospital, Piedmont Healthcare, Rockdale Medical Center, Southern Regional, St. Josephs of Atlanta, WellStar Health System.

Ambetter from Peach State Health Plan

Availability of Health Insurance Marketplace plans: 16 Georgia counties, including Fulton, Fayette and Henry in metro Atlanta.

Plan type: HMO

Details: Peach State is expanding beyond its business of managing care for Medicaid participants with its new health plan for individuals. The plan is available in only a few metro Atlanta counties; the hospital network includes Atlanta Medical Center system and North Fulton Medical Center.

Alliant Health Plans

Availability of Health Insurance Marketplace plans: 32 Georgia counties, mostly in northwest Georgia. Residents of three metro Atlanta counties can buy Alliant plans: Cherokee, Forsyth and Bartow.

Plan type: PPO

Details: Alliant’s “preferred provider organization” includes the Emory system, Children’s Healthcare of Atlanta, Northside Hospital system, St. Joseph’s, Gwinnett Medical Center system, the WellStar Health System, North Fulton Hospital and Tanner Medical Center. The plan also offers out-of-network care. Only a tiny segment of the Atlanta population can buy this plan, however, because of its limited distribution on the exchange.

A preferred provider organization, or PPO, enables you to use any doctor or hospital, although you will pay much more outside your network.
A point of service plan (POS) is similar to a PPO, except that you typically must get a referral to receive services out of network.
A health maintenance organization, or HMO, usually limits coverage to its network. If you go out of network, you may have to pay the full cost.