Patients Cram In Tests Before Health-Law Start - Some Top Hospitals and Experts Are Left Out of 2014 Plans Under Health Law

From The Wall Street Journal:

 

Thousands of people are cramming in tests, elective procedures and specialist visits before year's end, seeking out top research hospitals and physician groups that will be left out of some 2014 insurance plans under the new health law, health-care providers say.

Many insurers offering plans under the law are slimming down their networks of doctors and hospitals in a bid to lower the cost of policies, which begin coverage Wednesday.

Health insurers are especially focused on paring academic teaching and research hospitals from their networks because they generally charge more than community hospitals for similar services.

Ben Rosenthal, a 57-year-old freelance market researcher in Los Angeles, rushed to squeeze in a lung exam the day after Christmas. His new insurance plan under the health law won't cover care at Ronald Reagan UCLA Medical Center in Los Angeles, where he was referred under his current plan.

"I was forced to get it done this year," said Mr. Rosenthal, who said waiting would have required him to get a new referral for another facility.

The Obama administration said Sunday that more than 1.1 million people signed up for private insurance plans through HealthCare.gov by Dec. 24. Combined with numbers from Washington, D.C., and 14 states that run their own exchanges—including California, which said Dec. 23 it had more than 400,000 enrollees in private plans—that suggests a nationwide total of roughly two million people so far.

 

That is short of an administration estimate made before the Oct. 1 rollout of the health-care website that more than three million people would enroll in private plans through the exchanges by year-end. Enrollments accelerated recently, with more than 1.6 million signing up from the end of November to Dec. 23.

 

About half of Americans are covered by insurance provided by employers, according to the nonpartisan Kaiser Family Foundation.

 

The success of the new policies—and the marketplaces that sell them—depends in large part on how consumers react to the new networks, which are often more restrictive than the range of providers available in many current plans. More plans sold on the exchanges also require patients to obtain referrals to see specialists or receive insurer authorization before costly procedures.

 

Mr. Rosenthal's new plan from Blue Shield of California, for example, doesn't include UCLA's flagship teaching hospital, Ronald Reagan, or any facilities with which it is associated.

 

The health maintenance organizations of the 1990s, which were widely credited with holding down health costs then, encountered a broad consumer backlash over their restrictions on what doctors or facilities customers could use. But insurers say they believe things will be different this time because consumers care more about price than the range of doctors and facilities they can use.

 

Some 70% of new plans under the health law offer relatively narrow networks compared with many current plans, according to a recent McKinsey & Co. report.

 

"For exchange plans, it's about affordability and getting to a lower price point," said Juan Davila, an executive vice president at Blue Shield of California, which dropped about 40% of its physicians who didn't agree to lower rates for the new plans.

 

Many hospitals are part of broader health systems containing other hospitals, stand-alone clinics and physician groups. The exclusion of a single teaching hospital doesn't always mean that a health plan blocks visits to associated facilities or physicians. But health systems typically negotiate systemwide contracts with insurers.

 

The recognition by some consumers that their new plans won't always cover the facilities or doctors they want is triggering the boomlet in last-minute procedures, say health-care providers.

 

UT Southwestern Medical Center in Dallas has seen requests for complicated imaging tests and colonoscopies rise in recent weeks, said Bruce Meyer, an executive vice president. Barnes-Jewish Hospital in St. Louis has seen "dozens" of patients push up elective orthopedic surgeries, a spokeswoman said. Cedars-Sinai Health System, a top teaching hospital excluded from most exchange plans in the Los Angeles market, said it has fielded thousands of calls from people concerned about losing access and wanting to schedule elective procedures before Dec. 31.

 

"We have seen a big spike in December," said Thomas M. Priselac, chief executive of Cedars-Sinai Health System.

 

Some specialist groups also are seeing higher-than-normal volume this month. Illinois Gastroenterology Group, a team of 40 physicians, has seen "hundreds" of accelerated requests for colonoscopies in December due to concerns over access and higher deductibles in 2014, said Lawrence Kosinski, a managing partner.

 

Not all leading research hospitals say they have noticed a jump in patients moving up procedures to this year. Others, like University of Chicago Medical Center or UAB Hospital in Birmingham, Ala., aren't able to distinguish yet the reasons why certain patients have opted for an elective surgery. In addition, demand for some elective procedures normally rises late in the year in part because more patients have satisfied plan deductibles by then.

 

People can buy plans on the exchanges that offer coverage at a vast network of hospitals. But they cost significantly more, according to the McKinsey report, which analyzed markets where one insurer sold both broad and limited plans. The more-comprehensive coverage carried a median price increase of 26% compared with the slimmed-down alternatives.

 

"Not everyone can get a 50-inch flat screen. You might have to get a 32-inch. There will be segments of the population who can't afford to buy coverage to go to [every hospital]," said Paul Mango, a McKinsey director.

 

Still, consumers buying limited health insurance on the exchanges may not realize how restricted their access is, said Joanne Conroy, chief health care officer of the Association of American Medical Colleges, a nonprofit representing nearly 400 teaching hospitals and health systems. "We have a lot of people who aren't sick yet, don't need any procedures and will have a rude awakening when they realize they don't have access to the providers they want," Ms. Conroy said.

 

Daniel M. Adair, an orthopedic surgeon in Springfield, Ill., said one of his patients late last month moved up reconstructive knee surgery, even though the knee was in relatively good condition, on the chance it may encounter trouble in 2014.

 

The patient "told me, 'I don't know what's going to happen starting Jan. 1, so I might as well do this now,' " Dr. Adair said.