BCBSTX Canceling PPO Plans for 2016

[eytonxav]

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!!!!

 

[Gotadimple]

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).

Rita

 

[Gotadimple]

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!

 

[audreyh1]

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.

 

[utrecht]

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?

 

[easysurfer]

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.

 

[audreyh1]

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.

 

[utrecht]

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.

 

[Katsmeow]

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.

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.

 

[Lakewood90712]

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.

 

[photoguy]

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?

I think it's more of a cost cutting technique by the insurers. I.e. they only include the providers that accept the lowest payments (perhaps in return for more patient volume). Also if wait times go up, I'd assume that results in saved money as well.

 

[audreyh1]

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.

Individual insurance has the shrinking networks. The group insurance that employees have, still has access to the broad PPO networks.

 

[Gotadimple]

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.

As Katsmeow pointed out the doctors contract with several/many insurers.

For insurers, a limited network is a cost control technique. They are contracting with providers who have agreed to a lower rate for a higher patient flow. The provider is agreeing they have the capacity to see more patients (and with some HMOs to cap the number of patients they can see) for a lower reimbursement.

Providers (doctors, labs, and hospitals) have been at this 'dance' for many years now and know the techniques to assure they have patient flow at a rate that lets them cover overhead and make a profit.

- Rita

 

[MBSC]

FYI, but MD Anderson Cancer Ctr is not in their PPO network.

In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System, but it is not listed in the federal marketplace offerings so premium subsidies are not available.

Source: http://ifawebnews.com/2015/11/30/as-hmos-dominate-marketplace-costs-for-alternatives-increase/

From the Memorial Hermann Health website:

HMO Service Area: Harris, Fort Bend and Montgomery counties.
PPO Service Area: Harris, Fort Bend, Montgomery, Brazoria, Galveston, Walker and Wharton counties.
For individuals, find the rate that matches your age for the plan you’re interested in.
For families, find the rate that matches the age for all members of your family and add them together. If you have more than three (3) children, only add the rate for the three (3) oldest up to age 26.
The PPO is a Limited Hospital Care Network.

Source: Bronze Plans

Provider Network Search: http://healthplan.memorialhermann.org/individuals/find-a----/?searchfor=doctors
Rate Quotes: Individuals and Families Get a Quote