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.