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Old 11-16-2015, 01:31 PM   #41
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I've been pondering this exchange about MD Anderson and HMO v PPO. The reality is that MD Anderson et al are specialty care centers. That's one point.

The second point is that government agencies (Medicare and Medicaid) include MD Anderson because they discount the cost of care significantly. And, coincidentally, pass the losses on that care on to the private side insurers in their negotiations.

That MD Anderson's care is so great, it becomes a magnet for adverse selection, as Katsmeow pointed out. If it were an in-network provider, the plans would lose their shirts providing coverage to very sick populations. By keeping it as a specialty center, they can negotiate treatment on a case-by-case basis.

That brings me to the third point. With MD Anderson as part of a PPO, one can select to have their care with them without referral. But with an HMO, one must be referred to them. Just because they are not in-network for an HMO, does not mean that the plan wouldn't refer you out to them, if your case warranted their special services.

The same was true last year in Washington state, but, the hospital was Seattle Children's Hospital. They weren't in a majority of the Obamacare offerings. Plans couldn't afford to provide coverage if patients could self-select for care. But, if necessary and if they were the only place for the specialized care, plans would refer to Childrens.

Regarding the dearth of hospitals and labs in the Houston area: contact your state insurance commissioner, and your state legislators. I'm not familiar with Texas insurance regulation, but these plans must submit their network to the insurance commissioner, and one of the things they check for in addition to rates, is the breadth of the network. Specifically are there enough hospitals to serve the population in the region where the plan operates.

Just a thought.

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Old 11-16-2015, 03:01 PM   #42
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It is ironic that if someone in Texas who can't go to MD Anderson due to it being out of network were to move to another state, then that person (now a non-Texas) could change plans and perhaps could get a PPO that would provide out of network coverage to enable that person to go to MD Anderson.
As it happens my retiree insurance is a PPO with BCBS of Louisiana and since our costs increased so much for 2016 I had a look at plans I could buy and was also shocked to see how very narrow the networks were, and that we would have to switch doctors, hospitals etc. I hadn't noticed that MD Anderson was missing from the networks, only because cancer is not yet an issue for us.
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Old 11-16-2015, 04:29 PM   #43
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That MD Anderson's care is so great, it becomes a magnet for adverse selection, as Katsmeow pointed out. If it were an in-network provider, the plans would lose their shirts providing coverage to very sick populations. By keeping it as a specialty center, they can negotiate treatment on a case-by-case basis.

That brings me to the third point. With MD Anderson as part of a PPO, one can select to have their care with them without referral. But with an HMO, one must be referred to them. Just because they are not in-network for an HMO, does not mean that the plan wouldn't refer you out to them, if your case warranted their special services.
Can you provide some insight into how that works on a practical basis? If I've got cancer and my HMO's in-network provider is treating me with the standard chemo protocol for it (which hasn't changed in 20 years, with poor QOL and poor outcomes) and MD Anderson has more options, and they are more attractive? Or MD Anderson has several research trials going on that offer some promise, etc. Who ultimately decides if I'm getting appropriate care?
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Old 11-16-2015, 04:57 PM   #44
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Can you provide some insight into how that works on a practical basis? If I've got cancer and my HMO's in-network provider is treating me with the standard chemo protocol for it (which hasn't changed in 20 years, with poor QOL and poor outcomes) and MD Anderson has more options, and they are more attractive? Or MD Anderson has several research trials going on that offer some promise, etc. Who ultimately decides if I'm getting appropriate care?
That is what worries me. For many cancers, I'm sure that the treatment you would get from MD Anderson would be a treatment that you could get from X network provider. In that case, I think the insurer could reasonably say there was no reason to go anywhere else.

But, in many cases, MD Anderson may have trials going on that no one else really has. I'm personally doubtful that you could really get approval to go there. Maybe it is easier than it seems...but I wonder.

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Regarding the dearth of hospitals and labs in the Houston area: contact your state insurance commissioner, and your state legislators. I'm not familiar with Texas insurance regulation, but these plans must submit their network to the insurance commissioner, and one of the things they check for in addition to rates, is the breadth of the network. Specifically are there enough hospitals to serve the population in the region where the plan operates.
Leaving aside the MD Anderson issue, what I see on a lot of the individual market plans (both on and off exchange) is that they have a lot of hospitals on them in terms of numbers, but mostly they are not the "name" hospitals that are well known for quality care. They aren't the hospitals that I think most people in the area would ever think of when asked about hospitals. So, technically there are "enough" hospitals. It is just that they aren't really the hospitals that people want to go to.

Another issue is the lack of out of network coverage. I know that if I am out and about and have an accident and am taken to an ER (without my being able to say which one) that one of these HMOs/EPOs will cover the claim and pay what they would have paid in network. But, I'm still exposed to balanced billing and if I wake up 3 days later maybe the insurer will say I should have been transferred to an in network hospital after the first day and I'll have to fight for it to be covered.

If the hospital network is really broad (Cigna LocalPlus has a fair broad hospital network) then I don't have to worry about that as much as the odds go up that I am more likely to be sent to an in network hospital. The narrowed the network the more likely that I'll be sent to a hospital that is out of network.
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Old 11-16-2015, 05:46 PM   #45
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That is what worries me. For many cancers, I'm sure that the treatment you would get from MD Anderson would be a treatment that you could get from X network provider. In that case, I think the insurer could reasonably say there was no reason to go anywhere else.

But, in many cases, MD Anderson may have trials going on that no one else really has. I'm personally doubtful that you could really get approval to go there.
Maybe I am naive, but I don't think I have ever heard of insurance paying for an experimental treatment.

When I was working, a co-worker found out she had an unusual type of cancer. She spent several days at MD Anderson in Houston getting tests and a thorough work-up and diagnosis by a fine medical team there. Her main doctor at MD Anderson then devised a treatment schedule. She came back to New Orleans, and got her treatments here. Her doctor communicated regularly with the doctor at MD Anderson via videoconferencing so that both could see how she was responding to treatment and discuss how well it was or wasn't working out. Then she flew back occasionally for some in person checkups.

Even though her treatments could be done here, she still benefited from access to MD Anderson, and needed to be able to pay MD Anderson and the doctor and labs there.
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Old 11-16-2015, 09:40 PM   #46
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One thing that surprised DH and me in the offerings for 2014 was how aggressively priced the BCBS PPO pricing seemed.

DH was on a BCBS PPO individual insurance plan already. It had a higher deductible and higher OOP than was being offered with the new plans. It was not HSA compatible. His monthly cost would have been $478, but it was $351 with the new offering for the same network, lower deductibles and HSA compatibility. It was a no brainer for him, but of course he lost his grandfathered status.

At the time the Humana PPO quotes were $115 to $130 more per month - and would have been very close to what BCBS told him his new grandfathered PPO rate was.

Now I really wonder - well, we've wondered all along. Was part of their strategy to entice people to switch from grandfathered PPOs to the new plans, knowing they would drop the PPO option for the individual market at some point in the future?

Or were they just aggressive with pricing to get more folks to sign up with them, and then blindsided by the medical costs incurred?
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Old 11-16-2015, 10:19 PM   #47
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Maybe I am naive, but I don't think I have ever heard of insurance paying for an experimental treatment.
I'm not really talking about something experimental, just something that you can't get everywhere. Here is an article talking about an example of this in connection with the whole MD Anderson thing:

Loss of insurance plans could devastate cancer patients - Houston Chronicle

Where the line is drawn as for what is not covered experimental treatment versus something that is covered but just not available everywhere is unclear to me. From the article:

Quote:
The 59-year-old self-employed certified public accountant from The Woodlands area has a rare bone marrow disease that two years ago took a deadly turn, progressing to a form of leukemia so dire a doctor told her she should begin end-of-life care. But a Hail Mary plan put her in an experimental trial at Houston's medical crown jewel, the University of Texas M.D. Anderson Cancer Center. Against improbable odds, the treatment worked, dialing back her cancer from Grade 3 to Grade 1.



"Every day is a new miracle," she said, her honeyed drawl filled with awe.
Then came the Sept. 25 letter from her insurance carrier, Blue Cross Blue Shield of Texas, which said her Preferred Provider Organization (PPO) individual plan - one she picked specifically because, although expensive, it covered M.D. Anderson - was being dropped effective Dec. 31.


As many as 2,000 other patients at M.D. Anderson also may be cut off from coverage with the loss of such PPO plans either through the Affordable Care Act's federal exchange or, in the Gardeniers' case, bought privately in the individual market, said Dr. Lewis E. Foxhall, vice president of health policy at the cancer center.
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Old 11-17-2015, 01:06 AM   #48
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Just curious how people are finding out what docs and hospitals are on a plan....

I have tried looking on BCBSTX and it takes a LOT of clicking etc. and I am not sure that I am getting the info I need...
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Old 11-17-2015, 04:36 AM   #49
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Just curious how people are finding out what docs and hospitals are on a plan....

I have tried looking on BCBSTX and it takes a LOT of clicking etc. and I am not sure that I am getting the info I need...
Yes, it takes a bit of clicking and searching. One of the links I posted above gives hospital information statewide - links to specific regions for hospitals. The attached PDF shows the result of a different search.

But today I dropped by my main (specialist) doctor's office to ask a few questions and the office staff flat out said he is not in any HMO network. So why is he showing up online as a provider in the Blue Advantage HMO network?!?! This makes me rather leery.

Doctor's office called me back today to tell me that they talked to the biller, and yes, the doctor is in the Blue Advantage network. I'm glad they double checked - and glad they let me know. They have been getting a lot of calls from patients that will no longer be in the BCBS PPO.

Also - one of the concerns I had was the high lab fees billed, which are then cut down to about 10% by the insurance company. Well, it turns out the doctor's office works with patients. They have their own in-house labs that costs a self-pay customer about the same as my insurance adjusted amount, but nothing is submitted to an insurance company in this case. If you have insurance they send it to one of the labs so that it gets billed to the insurance company by the lab. And they will send panels to a specific lab upon request, and have for many customers.

So two more immediate concerns are addressed. There is still the bigger picture of broader network available and better out-of-network coverage of a PPO versus the new BCBS Advantage + offering.
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Old 11-17-2015, 10:24 AM   #50
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More indications that it's a good idea to call the provider:

I decided to check with my provider for mammograms, because I noticed that the hospital had billed my mammogram in 2015.

Well, that provider might still be in network, because the hospital itself is in network for at least a couple of things. Talking to "outpatient registration" they seemed to think that if the hospital is in network, their breast cancer center will be in network.

I'm not completely convinced with the BCBS Advantage Plan, as the hospital doesn't appear in the Advantage search and the radiologist appears on a different BCBS network, even though I got no radiologist fee this year for the PPO. But it is still possible.

It's hard to search as a prospective client. If I log in and search with my current insurance I get a very detailed list of area providers for a given service along with billing estimates! Not what the insurance company will cover, but it gives you an idea of the prices, and you can actually comparison shop.

This is a preventative procedure 100% covered under ACA, but the comparison shop is still useful information.
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Old 11-17-2015, 11:16 AM   #51
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In checking out the BCBSTX HMO for my daughter found a real deficit in the hospitals in the network. They were small, not the closest, and had poor ratings vs several other large quality hospitals that were previously available under the PPO option. Same with specialist coverage if one might need that. This plan is a major retrench in coverage at basically the same rate as this years PPO. I was expecting the HMO to have a much broader network of hospitals and Drs. Caveat Emptor!!!!
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Old 11-17-2015, 11:50 AM   #52
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Can you provide some insight into how that works on a practical basis? If I've got cancer and my HMO's in-network provider is treating me with the standard chemo protocol for it (which hasn't changed in 20 years, with poor QOL and poor outcomes) and MD Anderson has more options, and they are more attractive? Or MD Anderson has several research trials going on that offer some promise, etc. Who ultimately decides if I'm getting appropriate care?
Sam,
I can't speak for your insurer, but I can give you insight into the general protocols a health plan uses for members who have a chronic condition. Most plans have a group of nurse case managers. When the first claim is submitted indicating you have a chronic serious condition, such as cancer, you will be contacted by the case manager. His/Her job is to run interference for you and coordinate your care among the specialists you need to see. The point is to try and keep the cost of care down as much as possible, while assuring you quality of care.

So to answer your specific question: who decides? The Plan does. And if MD Anderson has a treatment plan that will help with your condition, you will be referred there. You would not, I don't think, be responsible for out of network coverage, as the plan has made the decision that MD Anderson is the most cost-effective way to get you quality care.

A call to Customer Service asking about nurse case managers should get you a clear explanation of the services they provide.

The other question: what if I am referred to a hospital that has statistically poor outcomes? You and your treating doctor should appeal the decision to send you to the specific provider. Your doctor needs to get into the discussion with the plan about quality of care and outcomes.

Plans get measured by outside evaluators on the quality of care they provide to their entire membership. If a plan wants to do business with government entities (CMS specifically), it needs to show that it's network has reasonable access, and that the providers are giving good care, and are meeting or exceeding national standards for treatment protocols (the time it takes to get a case resolved in an manner acceptable to medical professionals).

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Old 11-17-2015, 11:52 AM   #53
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In checking out the BCBSTX HMO for my daughter found a real deficit in the hospitals in the network. They were small, not the closest, and had poor ratings vs several other large quality hospitals that were previously available under the PPO option. Same with specialist coverage if one might need that. This plan is a major retrench in coverage at basically the same rate as this years PPO. I was expecting the HMO to have a much broader network of hospitals and Drs. Caveat Emptor!!!!
Good point, and also something to point out to your state legislators and the insurance commissioner. Inquiries from legislators are burdensome to a health plan, but it is a check on the decisions they make - especially if the insurance commissioner isn't paying attention!
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Old 11-23-2015, 04:17 PM   #54
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We really appreciate DFW_M5 giving us the heads up on this during the summer. I probably wouldn't have found out until well into October otherwise. This gave us time to prepare.

The rest of the year we've been very aggressive in taking care of any niggling thing we needed to have checked including getting up to date on immunizations, and I had my overdue colonoscopy which was no (extra) charge.
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Old 11-23-2015, 04:20 PM   #55
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For people talking about how narrow this or that network is...how do you know? Are you basing that on the total number of doctors on the list? Are you just checking to see if your doctor is on the list and suddenly he isnt?
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Old 11-23-2015, 04:31 PM   #56
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For people talking about how narrow this or that network is...how do you know? Are you basing that on the total number of doctors on the list? Are you just checking to see if your doctor is on the list and suddenly he isnt?
A lot of articles support this narrowing of networks. A sign of the times.

For me, my primary doctor and hospital is in-network, so I've decided to go with the slimmed down network to save money on the premiums but hope I don't need any specialized treatment (I'm currently healthy, no regular prescriptions).

Yet, say if I want to go to a big name university hospital in my nearby city, the are not covered in my plan.
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Old 11-23-2015, 06:47 PM   #57
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For people talking about how narrow this or that network is...how do you know? Are you basing that on the total number of doctors on the list? Are you just checking to see if your doctor is on the list and suddenly he isnt?
I looked up all our doctors, all the local hospitals and their associated physicians (such as anesthesiologists, radiologists, etc.), the local imaging centers and urgent care centers and clinics, the laboratory and pathology service companies.
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Old 11-23-2015, 07:11 PM   #58
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What is the point of shrinking networks? Almost nobody is going to use a doctor who is not in their network so how are these doctors who are being taken out of networks making money? It would be like a shoe store who will not sell shoes to anyone whose name starts with A, B, C or D....then next year they also eliminate E, F, G and H. Eventually they will go bankrupt.
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Old 11-23-2015, 07:21 PM   #59
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For people talking about how narrow this or that network is...how do you know? Are you basing that on the total number of doctors on the list? Are you just checking to see if your doctor is on the list and suddenly he isnt?
An important point is that it this type of thing is not just about the doctors. It is about the hospitals. I was looking at the narrow networks in my area and you can most clearly see it in the list of hospitals. I know what the major hospitals are in this area and they mostly weren't on there.

In most cases, if I was willing to change doctors there was someone who looked reasonably OK in this area. (There was one exception where the closest allergist for an adult was an hour away).

But the big thing for me was the narrowness of the hospital networks.

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What is the point of shrinking networks? Almost nobody is going to use a doctor who is not in their network so how are these doctors who are being taken out of networks making money? It would be like a shoe store who will not sell shoes to anyone whose name starts with A, B, C or D....then next year they also eliminate E, F, G and H. Eventually they will go bankrupt.
1. The doctor might not be in this insurer's network but might be that insurer's network.

But, even more importantly....

2. Most people in the US get insurance through group insurance through their employers. Those networks are usually broad networks. Basically the doctors in those networks really don't care if they aren't in the individual market networks.
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Old 11-23-2015, 07:36 PM   #60
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What is the point of shrinking networks? Almost nobody is going to use a doctor who is not in their network so how are these doctors who are being taken out of networks making money? It would be like a shoe store who will not sell shoes to anyone whose name starts with A, B, C or D....then next year they also eliminate E, F, G and H. Eventually they will go bankrupt.
I have always had PPO , in the last few years, my family physician referred me to a couple of specialists who were not in the PPO network , and one of those only accepted a particular HMO network .

Both physicians were were 60-70 years old. Both seemed to have few patients , gave rates for procedures that were in the ballpark of what would be paid by an insurance co. Maybe just enough patients who want their services enough to pay the out of network penalty. Semi- retired physicians ? It took some work with his billing and office manager to get a hard cost for a particular in hospital surgery. I did pick him, and paid the out of network difference.
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