Exchange Watch: Missing doctors, missing coverage

In New York, insurance exchange shoppers (if not enough reporters) discover the lack of out-of-network benefits

At the tail end of October, when the media were hyper-fixated on the woes of and who knew what and when about the site’s technical screw-ups, an important story appeared from Remapping Debate. The site does original policy-focused reporting, and this piece explored the lack of out-of-network coverage in the New York insurance exchange.

If mainstream New York news organizations—and national news outlets—saw Remapping Debate’s story, it should have been a clue that more reporting was in order. After all, New York is one of the biggest exchanges. (Some 2.7 million people have been uninsured in the state.) The debut of the exchange was a carefully controlled media event orchestrated by Gov. Andrew Cuomo. As I reported then, the big news the governor and his exchange officials were anxious to convey was that premiums in the individual market were dropping by an average of 50 percent in a state whose individual market rates have been among the highest around. The media everywhere seemed anxious to tout the Empire State’s good news.

Almost from the very beginning, exchange officials in New York have been stingy with information. So it’s hardly a surprise that officials haven’t been eager to discuss the scarcity of out-of-network benefits for exchange shoppers. The lack of these benefits means consumers are on the hook for the full price of care should they choose non-network doctors or when they have no control over the providers who may care for them in an in-network facility. (This is a problem, of course, that consumers buying insurance faced well before there were insurance exchanges). If you need a quick appendectomy, you may have to settle for a non-network surgeon or anesthesiologist.

Remapping Debate’s Craig Gurian talked to New York Department of Health officials who allowed insurance companies to decide whether to offer out-of-network benefits as part of their coverage. The Health Department’s director of plan management, Randi Imbriaco, told Gurian: “We left it up to the insurers. A closed network helps keep the cost low.” In other words, those low, low premiums state officials touted in July come with a cost. If you go out of network, you pay for the cost of your care. Gurian asked if it would be useful for consumers to choose a plan with out-of-network benefits even if they had to pay more. Imbriaco gave the same answer. “That was a choice made by the insurers,” she said. “And they decided not to [offer that].” (It’s ironic that shoppers in New York may want the choice to go out of network, but the exchange—which is supposedly all about choices—denies them this choice.)

Remapping Debate explained the ever-growing tussle between providers and insurers, and who has the most leverage to beat down costs—an underexplored topic. In fact, that’s a major story as the Affordable Care Act continues to roll along. It boils down to who has the upper hand: docs or insurance companies? This is a battle that is being fought all over the country as the exchanges crank up their business. The outcome will determine what medical care will cost in the future and who will pay for it—insurers or patients.

So far, coverage of this negative news about New York (the lack of out-of-network benefits in exchange plans) and the implications for the rest of the country falls short. In a July piece on the exchange announcement, The New York Times gave a nod to the fact some providers would not be in every insurers’ network, but it did not address the lack of out-of-network benefits. Limited networks are a related access problem. Some press stories have noted the narrow networks, like the trade pub LifeHealthPro which in November advised consumers to “read the fine print if they’re interested in getting care at some of the city’s top hospitals,” like Memorial Sloan-Kettering. At the end of November, that hospital was not on the lists of plans selling on the New York exchange. In mid-October, CNNMoney briefly noted the out-of-network problem, reporting patients “have to stick to a certain set of physicians and hospitals or foot the full bill themselves.”

In October, Times money columnist Tara Siegel Bernard offered a good, enlightening, and useful piece about what happens when families find themselves with big bills from out-of-network doctors they didn’t expect to use. “When the doctors work in the hospital, not for the hospital, which is often the case, they’re not obligated to join the same networks as the hospital,” Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told Bernard. That’s a good consumer tip for reporters.

While the press appears to have missed the lack of out-of-network benefits, exchange shoppers have not, and some are unhappy. One Manhattan hairdresser told me she probably wouldn’t buy an exchange policy and would instead keep her existing insurance because, “I’m not clear who the doctors are and who the hospitals are.”

Courtney Lee Adams, a New York freelance writer and editor—and avid CJR reader—contacted me to talk about her shopping experience in the New York exchange. Once she managed to create an account with what she described as a confusing and not very helpful website, she discovered her primary care doc of 15 years would not accept insurance from any plan on the exchange. It came down to reimbursement, she said. No out-of-network benefits meant she’d have to find a new doctor or pay on her own and made peace with those options. Then she faced a new obstacle. She found a hospital network in lower Manhattan she liked and trusted to deliver good care. But who were the doctors in the network? Each call to find out brought different answers. “As I get down to the deadline to purchase coverage effective January 1, I find comparison shopping among plans nearly impossible, mostly because of conflicting information about provider participation in plan networks,” Adams said. She added that many providers listed on carriers’ sites as being in-network have told her that they are not even accepting the plans.

There’s plenty of material here to move the insurance exchange story along beyond cheap premiums and technical glitches that continue to plague some states. Shoppers could use more stories like Siegel Bernard’s for the Times—advice via anecdote. But there’s also an important and larger story here about the ongoing payment wars between medical providers and insurers over which party can extract the best price for its bottom line. As Adams, the freelancer shopping for insurance in New York, told me: “This is not just a consumer shopping story. It’s something deeper. They’re wrangling over money. It’s not just about consumer choice.”

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Related content:

Exchange Watch: New York: What’s going on with New York?

Exchange Watch: Are New Yorkers getting a bargain?

A magazine editor shops for health insurance

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , , , , , ,