A leaner, meaner network
Last week the health insurance exchanges, or marketplaces, opened for business. Many potential insurance buyers were met with non-working or glitchy systems on that first day, but slowly these technical issues are being resolved.
I tried my state’s wahealthplanfinder.org the first day, and I, too, ran into performance issues. The following day, however, I had no problem accessing the site. I could make a few suggestions as to how to improve the look and function of the website, but I was much more interested in content–what plans are available and how much do they cost?
Because I have followed the progress of the plans through the approval process in the insurance commissioner’s office, I was not surprised to find that the plans are pretty costly for the average family (in my opinion), and the out-of-pocket costs are quite high. Deductibles for the silver and bronze plans run from $1,500 to $6,350.
Subsidies for those who qualify will make the monthly premiums more affordable.
What did surprise me, however, was how much smaller the provider networks were than I had anticipated.
The website is a bit clunky in this regard, in that you can only plug in one doctor or one hospital at a time. It’s hard to get an idea of the breadth of the provider network this way. I’d much rather access a complete list.
Still, I took the time to plug in the names of several doctors my family uses, as well as the hospital we have always used.
As you can imagine, I was extremely disappointed to find that neither our doctors nor our hospital would be “in-network” for these new plans.
The insurance companies on the exchange are major players in the individual health insurance market, such as Premera Blue Cross and Lifewise. I had just assumed they would offer the same networks as they always have, networks that included my doctors and hospital.
Seattle’s largest pediatric hospital is also not available, nor is the Seattle Cancer Care Alliance facility.
Lesson learned: Don’t assume!
I have been reading warnings in health news for some time about how insurance companies would be offering fewer provider choices–narrow networks–on the exchanges. But for some reason I thought this wouldn’t apply to my choices.
I understand the economics behind the narrow networks. A smaller number of providers and facilities contract to accept smaller reimbursements, and the insurance companies save money.
Faced with having to provide essential benefits to all health care consumers–even those with health care costs running into the hundreds of thousands of dollars–insurance companies will negotiate lower prices wherever they can.
A smaller choice of doctors and hospitals is one of the sacrifices we must accept so that people with pre-existing illnesses can buy insurance.
But don’t assume, like I did, that your current health care providers will be available to you. Take time to browse online, or call the insurance companies directly, or use an insurance broker or navigator, if you have to, to get clear information about what providers you can or can’t use.
Making difficult choices
What are your choices if you don’t want to change your doctor or hospital? Not many.
- Research health plans being offered off the exchange, if you are absolutely sure you will not qualify for a subsidy. These plans might offer broader networks.
- Buy a plan through the exchange if you think there is any chance your income will fall at or below 400% of federal poverty level. Getting a subsidy could save you hundreds or even thousands of dollars every year. How much is keeping your doctor worth to you?
- Find out the penalties for using a doctor or hospital that is out-of-network. Unfortunately, these extra costs will probably be high. Deductibles can be doubled; co-insurance after the deductible is met can still be 50% of costs; and the out-of-pocket maximum could be unlimited.
- Talk with your doctor(s) about how to make the transition to a new care team easier and safer. It could take some time, even in this digital age, to gather your records and transfer them to a new doctor or doctors. Do it well before you need to make an appointment with your new doc.
Safety and continuity of care
You might find that your doctor is in-network, but not the hospital you usually use. “Well, one out of two is better than none,” you might think.
Be cautious with this arrangement. Most doctors have privileges, or can use, more than one hospital, but they still use just one hospital the majority of the time and are most familiar with its staff and procedures.
Doctors using hospitals with which they are less comfortable is a recipe for medical mistakes. In general, it’s safer for you if your doctor is in the most familiar surroundings!
For many reasons, it’s lousy if you need to change doctors, especially if you are currently undergoing treatment. It takes time to build a relationship with your doctors. I fear that patient-doctor relationships and continuity of care will both suffer as a result of network diets.