Frozen Out of HIX, NH Hospitals Feel Burned

New Hampshire hospital leaders are crying foul over being squeezed out of the single health insurance exchange plan available in the state. Anthem says offering a 'select network of providers' will offset premium increases.

Healthcare providers from Maine are being shut out of health insurance exchanges, but in New Hampshire, hospitals shut out of the state's insurance exchange network are not going quietly.

See Also: HIX Pains Now, But Hope for Long-Term Relief in NH

"Anthem [pays] providers at pretty much Medicare rates," said Scott Sloane, vice president of finance at Concord Hospital. "Over the long term, it's a really bad idea." Concord Hospital, based in the state's capital, is a non-profit regional medical center with 295 licensed beds.

While top officials at the out-of-network hospitals are concerned about the long-term financial effects of Anthem's narrow network, they are nearly apoplectic over the implications for two key goals of the PPACA reform effort: improving access to healthcare services and boosting population health.

'Swimming Against the Tide'
"It's not a money issue for me," said Maria Ryan, CEO of Cottage Hospital, a 25-bed critical access hospital in Woodsville serving 26 New Hampshire and Vermont towns. "It's making sure [the patients] stay healthy. I'm swimming against the tide now when it comes to making sure they are compliant and making their appointments."

She fears Anthem Pathway patients using population health programs, such as one for diabetes education, will stop if they have to drive as far as 90 miles for services at one of Anthem's in-network hospitals. "Transportation is a big issue for them," she said of Cottage Hospital's patients.

"I have to look at the overall health of our community," Ryan said. "We are hearing loud and clear from the patients, who are heartbroken over having to leave their primary care doctors."

'A Select Network of Providers'
An Anthem official says the insurer is living up to the spirit and letter of the healthcare reform law.

"A major goal of the ACA was to provide more affordable healthcare, " said Chris Dugan, Anthem's NH communications director. "While all other carriers in New Hampshire are sitting on the sidelines, Anthem Blue Cross and Blue Shield in New Hampshire is proud to be part of an effort to provide coverage for many who have not previously had insurance. We are offering this select network of providers to offset premium increases that would otherwise be necessary in 2014."

Dugan says attaining that affordability goal posed a challenge in building the Pathway network. "Independent studies performed by both the New Hampshire Department of Insurance and the Society of Actuaries predicted that the average increase, driven primarily by higher claims of the previously uninsured and those covered through existing high-risk pools, could be significant, [by] as much as 30 to 40 percent," he said.

A 'Huge Financial Burden' for Hospitals
Cottage Hospital's Ryan and leaders at several of the nine other out-of-network hospitals in New Hampshire say that requiring Anthem Pathway patients to travel long distances for healthcare services will hurt many.

Charles White, COO of non-profit Upper Connecticut Valley Hospital in Colebrook, NH, says Anthem's narrow network could have a devastating impact on residents in the hospital's 850-square-mile service area, which is the largest in the state. With just 16 beds, the critical access facility is the smallest hospital in the state.

"We're a very fragile economic and medically served area," White said, noting that the region has the worst health outcomes in the state, no public transportation, and a relatively high number of patients suffering from costly chronic diseases. "This network hurts those patients who don't have the financial means to stay healthy."

UCVH was one of five out-of-network hospitals contacted for this report and the only one where officials said they are committed to continuing to treat local patients if they are in the Anthem Pathway network. "Our mission is to provide healthcare to the patients we serve," he said. "If we have to find a way to lower fees or provide free care, we will."

White says denying local care to patients in communities served by UCVH could have dire consequences. A few years ago the hospital had considered dropping chemotherapy because there was another facility within 90 miles offering the service.

But the reaction from the community was shocking, White said, with some patients saying they had no way to get to the other facility and others reluctant to impose "a huge financial burden" on loved ones to drive them to appointments.

He summed up the reaction in chilling terms: "They told us, 'We're going to choose to die instead.'"

Anthem Pathway a 'Comprehensive Provider Network'
Anthem's Dugan says it was necessary for Anthem to narrow the Pathway network to hold the line on premium increases. "Without the use of the new network, all individual exchange members would have seen much higher premiums than they will now see."

Anthem's exchange network in New Hampshire includes the vast majority of physicians in the state and is well within regulatory bounds, he said. "Pathway is a comprehensive provider network that meets or exceeds New Hampshire's network adequacy requirements."

Despite leaving out 10 hospitals in the state, Dugan says Anthem was able to include 78 percent of primary care physicians; 87 percent of specialists, allied and other professional providers; and 87 percent of ambulatory surgery providers.

Raising the PPACA alarm
Alvin Felgar, president and CEO of Frisbie Hospital in Rochester, NH has been one of the most vocal critics of Anthem Pathway, pressing the state legislature to force Anthem to broaden its network, and seeking to energize the community into action with a billboard, an open letter on the hospital's website, and an opinion piece published in the New Hampshire Business Review.

"We have real and practical concerns about the impact of the Affordable Care Act," Felgar wrote in the open letter. "Our hospital is not part of the process. We are on the outside looking in, and it is entirely possible this new law will serve as a wedge between our doctors and our patients."

In addition to the transportation challenge many of his patients face, Felgar said in an interview with HealthLeaders Media that compelling Anthem Pathway patients to change doctors poses another access obstacle. "It's a daunting process for people, especially people who have multiple health problems," he said of finding a new physician. "It's not a simple process."