BY THE TIME this article is published, we expect the following to have become a reality: There has been a whirlwind of concern over the recent news release from Blue Cross/Blue Shield of North Carolina that their contract with Carteret Health Care will expire as of Jan. 31, 2016. That throws Carteret Health Care into an “out of network” status for Blue Cross patients, increasing the cost of care for their clients. The recent news release and other statements by Blue Cross appear to be part of a negative public relations campaign to force the hospital to accept its demands in a new contract.
With the introduction of the recent federal health care legislation, many of us have Blue Cross policies because they were the only choice available in Eastern North Carolina. Most employers offering insurance use Blue Cross, and Blue Cross is the only insurer offering “Affordable Care Act” compliant individual policies in our part of the state. This has given them enormous power over providers, and we are seeing that power used against our community hospital.
Carteret Health Care has had a stable and equitable contract with Blue Cross for decades. It was an “old fashioned” contract and probably needed to be updated, but the changes Blue Cross demands in a new contract may jeopardize the long term viability of our community hospital. We encourage anyone with Blue Cross insurance who values the availability of our community hospital to contact Blue Cross and encourage them to come to a fair compromise so that their policy holders can have access to local hospital care.
So, what does this mean to you? If you have Medicare with Blue Cross as a secondary insurance, there should be no changes. The secondary insurance just covers the 20% “co-pay” and otherwise follows the Medicare regulations, which do not differentiate between in- or out-of-network status. Also, any emergency care, including emergency hospital admissions, are covered by Blue Cross as if they are in-network no matter where you go.
If you have one of the primary Blue Cross policies (including state and federal employee plans, employer group policies, Obamacare, etc.), then you need to check whether you have out-of-network coverage. Most policies have such coverage, but it usually includes higher co-pays and deductibles with separate limits. This is where your potential financial liability could increase dramatically. Say, for instance, you have a Blue Cross policy with a $3,000 deductible for in-network care and a separate $6,000 deductible for out-of-network. If you need an elective hospital surgical procedure, your surgeon is likely in-network and that fee will be applied to the $3,000 deductible. If you have the surgery in an out-of-network facility, then the facility fee is applied to the $6,000 deductible, making your potential cost up to $9,000 before Blue Cross pays anything on your behalf. In order to offset this liability, Carteret Health Care has implemented a new discount for out of pocket expenses if they are out-of-network with your plan.
There is another dimension to this problem that few people consider. The other “customer” of Carteret Health Care which will be impacted is the local medical community. Some physicians are directly employed by the hospital, but most are independent practitioners who are looking out for their patients as well as their businesses and employees. Almost all of these practitioners rely upon the local hospital for at least some of their services, and almost none have admitting privileges at other hospitals. With the news that Carteret Health Care will be out-of-network with Blue Cross, many people have assumed they will have to find new doctors out of town. However, in most circumstances that is NOT TRUE!
Essentially none of the medical and primary care physicians admit their own patients to the hospital anymore. Inpatient care is left to the hospitalists, and emergency admission to the hospital is covered by Blue Cross at normal in-network rates.
It is mainly the non-emergency hospital services such as laboratory testing, advanced diagnostics (XRay, MRI, CT), childbirth, cancer treatments and elective surgical services which will be impacted. Your doctors can find local alternatives for laboratory testing, advanced diagnostics and many other outpatient services. Outpatient surgery can also be done locally.
However, the real problem boils down to those practices which rely on IN-PATIENT hospital services such as obstetricians and surgeons. If care requires a hospital – think childbirth or total joint replacement – then patients may feel forced to seek alternatives to Carteret Health Care. But that does not mean people must find a new doctor. Your own local physician can help arrange appropriate care at appropriate locations.
Some have affiliations with surrounding hospitals and can perform your surgery there with follow-up care at home … just ask us. Or you can go to the Blue Cross website and search for doctors in your desired field who have privileges at your desired hospital. Be sure to look for one who has an office close to home and is on the ACTIVE medical staff, which means they have admitting privileges without limits. For instance, you will see that Dr. Moore is on the active medical staff at Carolina East in New Bern but has offices in Morehead City and Cedar Point.
It took an entire generation to build the medical community in Carteret County to what it is today, which is quite good for such a small town. Since Blue Cross commands about 35% of the local insurance market, the potential loss of business could be devastating to our practices. If practices close and physicians move away, it will take another generation to build it back. So, in this time of uncertainty about your local hospital, please continue to support your local doctors.
Again, we encourage anyone with Blue Cross insurance who values the availability of your medical community to contact Blue Cross and encourage them to come to a fair compromise so that their policy holders can have access to local hospital care.
We continue to expect and hope any lapse in the contract between Carteret Health Care and Blue Cross will be short lived.
Moore Orthopedics & Sports Medicine Team