Narrow Networks – Part II

For the past six years, Harvard Pilgrim has offered a limited
network product to our New Hampshire members called “New Hampshire
NetOption.”  Simply put, all New Hampshire providers are Tier One
providers – lowest co-pays – and so are all Massachusetts community
hospitals.  Tier Two providers are MA-based teaching hospitals (members
have a higher co-pay for services there).  That’s it.  Two tiers – one
for NH hospitals and MA community hospitals, and a different one for
MA-based teaching hospitals.

There is, however, one catch.  All NH hospitals and their physicians
and all MA hospitals and their physicians are “in network” for this
product – except Partners.  When we set the product up, Partners chose
not to participate because the plan design treated teaching hospitals
differently than it treated community hospitals.  That’s their call. 
NBD, as my kids would say.

Fast forward six years later, and we’ve sold quite a bit
of NetOption in New Hampshire.  And why wouldn’t we?  It’s a pretty
solid plan design, it has a great price point, and it offers access to
virtually every hospital system in MA, NH and ME.  It’s not quite
a narrow network product, but it’s close.  And for most people who work
for employers who purchase this product, it works – beautifully.

So here are two real-life examples – names changed to protect the
innocent – that explain why narrow networks – you know, network
products that have local out of network providers - can be hard to
manage.  The first involves someone I know who called me up about a
relative and said, “Hey – my brother lives and works up in New
Hampshire and he’s got something wrong with his back that looks like
it’s going to require surgery.  He really wants to go to this doctor in
Boston at Mass. General.”  At this point, knowing nothing else, I said,

“Well, his company has this product – New Hampshire NetOption – and
from what he tells me, Mass. General doesn’t take it.”  To which I
replied – “Yup.  That’s correct.”  And then the dance began.  In this
case, we/I didn’t bend on the terms of the agreement – and frankly,
there were literally dozens of hospitals in MA and NH that were
perfectly fine alternatives to Mass. General to meet this member’s
needs.  And we found him several options, he took one, and it all
worked out well.

But his brother is still mad at me for not letting him go to the General.

The second example is even more complicated, because Partners
physicians are now practicing in many community hospitals in Eastern
Massachusetts and Southern New Hampshire that are NOT Partners
hospitals.  This involved an individual – a loyal customer – one I’ve
used as a reference for Harvard Pilgrim in selling to other mid-sized
businesses in New Hampshire – who called me up over services rendered
to his wife at a New Hampshire hospital.

The physician who provided the services was a Partners physician
practicing in a hospital in Southern New Hampshire.  The physician was
not identified as a Partners physician, and someone enrolled in our
NetOption product who knows how it works would never know that they
were seeing an out-of-network clinician – because they were in a New
Hampshire hospital at the time.  My customer said, in effect, that this
situation didn’t pass the reasonable person test.  I admit, he had a
very good point.  His wife was in a New Hampshire hospital seeing what
she assumed was a New Hampshire physician.

I would argue it’s incumbent on the clinician to notify the
scheduler at the hospital that he or she can’t/won’t take New Hampshire
NetOption members, since Partners does not participate in the product. 
The clinician would argue that’s too complicated to keep track of that
at the hospital.  The member would – and did – argue that if they go to
a New Hampshire hospital for services, it’s a New Hampshire provider,
and should be considered an in-network service.

Pretty sticky wicket, these narrow network products.

And by the way, New Hampshire NetOption continues to sell and do
very well in New Hampshire.  It’s a good deal and a good buy.  But it
is made complicated by issues like this – which can seem to some in the
employer and member community like “noise” - but represent exactly the
reasons why this product costs less than most all-in, open access
products with similar benefits.

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8 replies »

  1. The woman was in a hospital, an in-network hospital. Do you expect in-patients to query each physician that walks into the room whether they take a particular insurance or not?

  2. Patients are reluctant to ask doctors to wash their hands, you think they are going to ask about insurance/professional affiliations? The hospital context provides the certification for patients, if you go to a restaurant you do not go and examine the health department inspection certificate, you assume it is OK.

  3. Nate, why do you keep talking about dinner and oil changes? The woman in the story was in a Hospital. She was not having a scheduled physical. In the automotive world that would qualify as an accident and it would be covered.
    “Why do providers care who your insurance is?”
    Maybe because all the bureaucracy and contracts and the variance in what payers actually pay. If there was one single fee schedule regardless of payor and/or provider, nobody would care. Shifting the responsibility to the patient and allowing providers to charge whatever they want and payors to pay whatever they feel inclined to pay, and call it “consumer choice” and “patient involvement” is pretty cruel.
    And by the way, body shops will work with your insurer to get paid directly. Not that I think that the car insurance model is a good model for healthcare.

  4. Margalit Gur-Arie are individuals responsible for anything in their life anymore in your world view? Do you walk into any restaurant and expect they take your discover card or Euro dollars? Individuals show enough personal responsibility to pay for dinner why can’t they be expected to do the same for health care?
    You make it sound like a non contracted physician in a contracted hospital is some shocking abnormality. This is quit common and the norm in most major hospitals. Anesthesiologist are a pain in the A$$ to get contracted as our Radiologist. Before the major consolidation in labs they were frequently non network as well.
    Your usage of terms is quit telling of the problem, “query each physician that walks into the room whether they take a particular insurance or not” Why do providers care who your insurance is? The relationship between your insurance company and you should have nothing to do with your doctor and the care he delivers. When you get your oil changed or your car repaired do they take your insurance or not? You don’t insure oil changes and your auto insurance reimburses you not the auto body shop. This is one of the reasons our system is messed up, what we call insurance is not insurance it is a very inefficient financing method. Return insurance to what it really is and a number of problems will be solved and a number more easier to fix.

  5. These stories illustrate the absurdities of our current health care ‘system’. As insurance companies try to carve out niches where they can make a profit, patients run afoul of arcane rules.
    It is really time to do away with all of this nonsense and adopt a single payer system. I trust the government to adopt sensible uniform procedures so I don’t have to play Russian roulette (literally) with my health.

  6. Here’s an idea: have every patient in the hospital wear their insurance card around their neck, so doctors know not to touch them if they are not contracted with that particular plan.
    Are you serious, Nate? The woman was in a hospital, an in-network hospital. Do you expect in-patients to query each physician that walks into the room whether they take a particular insurance or not?
    The way I see it it’s the hospital’s responsibility to sort these things out in advance.

  7. In non emergency situtions is it to much to ask members to verify the participation of their provider? In a perfect world one would hope all the providers praticing at a hospital would have common contracting but that is far from reality.
    I would argue this very detachment is what causes the problems. In exchange for a substantial discount in your insurance premium you are required to see specific doctors. If that is to much hassle for someone, speaking only of non emergency care, then buy an indeminity plan.
    If they don’t know the contracting status of this doctors do they know if he is board certified, how many malpratice claims he has had, what other patients think of his bed side manner?
    When people put more thought and research into where they are going to dinner after seeing the doctor then what doctors they are seeing we have a problem. We need to stop coddeling members and force them to be engaged and take responsibility.
    I’m not offering to be the first payor to implement this of course.

  8. Charlie,
    Do you think Partners will loosen up on this issue and enable HPHC and other local plans to offer them as a third tier option, or even as a participant in the second tier? That seems to be a worthy goal of the Governor’s Payement Review Panel. A product like this would have a meaningful impact on total healthcare cost as more consumers will feel comfortable choosing products like NetOption if they have the ability to go to a branded AMC, even though the vast majority will rarely, if ever, have the need to go. Interested in your thoughts.
    Dave Terry
    Salvectus Healthcare