Some NY Hospitals Opting Out of Health Exchange Plans

Monday, October 07, 2013

Health Republic allows members to use hospitals that are not included in many exchange plans, including Memorial Sloan Kettering Cancer Center and NYU-Langone Medical Center. (Fred Mogul/WNYC)

If consumers buying insurance on health exchanges have their heart set on particular hospitals or doctors, they better do their homework.

Some hospital systems, such as NYU Langone Medical Center and New York-Presbyterian Hospital, are available as in-network choices in relatively few of the plans offered on the New York state exchange. Other systems, such as Mt. Sinai, Northshore-LIJ, Montefiore and Maimonides, are available in many more plans.

“We were able to come to some good agreements with plans,” said Kate Rose, senior director of public policy and government relations at Montefiore Medical Center, which dominates the Bronx health care market and is expanding into southern Westchester County.

Consumers can go to whatever hospitals and doctors they want, but other than for emergencies, their insurance plans only guarantee payment, if the provider is in-network. If not, providers can charge patients whatever they want. (There are some plans that allow out-of-network options, but they tend to be either limited or expensive.)

Networks are a result of negotiated contracts the two sides agree to. Insurers say that the best way to limit costs to patients is to drive a hard bargain with providers – and offer them less money for treatments and tests. If hospitals and doctors don’t think the price is right, they do not go into the insurer’s network.

"Some of the plans are offering us extremely low rates," said Dr. Neal Calman, head of the Institute for Family Health, a community clinic in the Bronx. "They claim they are putting their premiums out on the street at a very low rate to make them affordable, but we can't afford to see these patients for the same amount of money that a private doctor in his office with one assistant can."

Calman's health center is in-network for three insurance exchange plans. Most of the rest wanted to pay him less than the special rate he gets from Medicaid for taking high-needs patients and providing them not just with primary care but also dental care, mental health counseling and some social services.  

But some consumer advocates say insurers and providers need to work harder to make sure networks are broad enough to serve all the newly insured. 

"We need all hospitals and health centers to accept all plans," said Judy Wessler, former head of the Commission on the Public's Health System. "Many communities already have access problems, and as we add more people it could get worse."

Many providers say negotiations with insurers are ongoing, but here are some examples of major New York hospitals and how many insurance plans for individuals they are participating in, as of October 1:

  • Montefiore will be in-network for seven out of the nine insurance plans offered in the region—all except for Fidelis Care, a Catholic non-profit, and MetroPlus, the insurance arm of the city’s public hospital system.
  • Mt. Sinai Health System, which recently grew to include Beth Israel, St. Luke’s Roosevelt and other facilities,  is in-network for six insurers.
  • Maimonides Medical Center, in Brooklyn, is in-network for five.
  • Medisys, which includes hospitals in Flushing and Jamaica, is in seven plans.
  • Brookdale Hospital is in four.
  • Northshore-LIJ, the state’s largest hospital system, has its own insurance plan – and is in-network for five others.
  • NYU is in-network for three insurers, Fidelis, Affinity and United.
  • New York-Presbyterian is in-network for United, Emblem and Aetna.

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    Matthew Schuerman


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    Comments [13]

    NCelini from 10979

    Why isn't every major publication all over this story and terrible outcome? If we are to lower costs everyone must be in the pool, this barrier, that the finest medical centers and perhaps physicians, are only taking the cream of the crop plans, diminishes and defeats the entire concept and ability to distribute this shared medical burden. What a shame or shall I say SHAM that the insurers continue to walk away with the prize? What about the patient. Is best in care only for the top 1%?

    Mar. 09 2014 07:06 PM
    bernard from new york city

    the problem with the implementation of the ACA in NY State is two fold. The first is the NY State which had a poorly coded web site that failed to list clearly who accepted what insurance and which hospitals would be accepting which insurance.

    The second was the hospitals and private providers(MD'S ETC). There was no way to pick and choose insurance coverage and know what companies (insurance) was accepted by which facilities and individuals. It was basically impossible to uncover which policy would provide for the important continuity of care needed for excellent care by allowing for one to continue with the same physician and same facility. Of course NYC is a atypical of other places with its large number of facilities in such a small area (25 mile radius) but a simple spread sheet download would have been all that was needed to see globally which providers serviced which facilities and which physicians. Because of this confusion for the consumer as well as the opt out and opt in guidelines not being clearly defined with a time based period (that is a facility or individual could not within a certain period of time just drop out of accepting insurance) the notion that the consumer could make a decent educated choice is all but absent.

    If we as consumers are at the mercy of a hospital or individual provider (MD) one week taking certain coverage policies and then turning around the next and dropping out, the consumer is left holding the bag with a policy that perhaps they would not have chosen if they had known that the facility and or physician was going to discontinue accepting a certain insurance.

    Jan. 20 2014 10:05 AM
    suzie from NY

    so tired of hearing about highly paid doctors: here's what I know from up-close personal experience

    as a resident worked 60-70 hrs a week for 52k a yr
    earn 170k now
    minus state and federal taxes equals 90 k
    minus student loans which will go on forever 2500 a month equals 5000 a month
    not poverty but SURE NOT RICH

    yes some specialties do have exorbitant fees based on procedures

    Dec. 23 2013 12:49 PM
    Brooks White from Brooklyn, NY

    Why are hospitals allowed to choose? They are regulated by NYS DOH and they should be required to participate at every plan level with a full panel of their doctors as a condition for continuing to operate. The State Legislature should take this up. The current approach will further squeeze the middle class by tiering hospitals, particularly for those with family plans or who need specialists for chronic or rare conditions. ACA is not only about price, it is about supply, which is why hospitals have intentionally been gaining leverage through consolidation and increased employee doctors. Antitrust exemption will need to be revisited. Allowing hospitals to cherrypick will ultimately defeat ACA.

    Oct. 10 2013 11:40 AM
    Dudley Smith from New York


    Individual plans under the ACA can be written on or off-exchange. The ONLY reason why someone needs to take out a plan on-exchange is if they need premium subsidy assistance. Otherwise, you can avoid the government-run sites all together by writing a plan off-exchange.

    Some carriers are writing on-exchange only. Some are writing off-exchange only. Some are writing both on and off-exchange. According to the NYS DFS, Aetna is writing both on and off-exchange for the individual market, and off-exchange only for the small group market.

    Oct. 09 2013 09:45 AM
    Aridan from New York

    "Wing Clipper" be careful what you wish for. As Dr.s wings get clipped,certain industry MDs will not survive, to which some may be pleased with. However these MDs will be forced to join a hospital based system which has happened over the past 5-7 years Nationwide. As your MD becomes an employee of the hospital, your options and their approach towards medicine might be altered and limited as they must listen to a higher power to ensure their employment. America should be prepared for the migration of medicine .... MDs will be acquired by hospital systems, protocols and payment will now be between govt, insurance companies and hospital systems. Physicians will provide a service equivalent to that of any other hospital based employee, under the protections and mandates of the institution.

    Fee negotiations / payment terms with pt's will become less acceptable / tolerated, greater collections pursued as insurance companies chew down hospital based re-imbursements in the near future. Hospital systems need to generate profits as do insurance companies, hence cheaper MD care or other equivalents will be pursued and acquired. Will your MD punch in and punch out- leaving another responsible during off hours? 10 years from now... "Your out patient doctor (if not acquired by a hospital system) will only function as a visitor and not provide care for u in the hospital or have access to your chart. I recommend obtaining a Cadillac style insurance (equivalent to what congressional leaders hold) Insurance that specialty centers take and accept, along with top notch MDs.

    The ACA has made annual premiums for insurance costs 6 to 7k cheaper - great ! The problem is when u get ill and acquire 100k in medical bills for an unexpected illness or life event. Your health care exchange or discount healthcare insurance policy may not be accepted and lead to greater out of pocket costs to you and your family. Car insurance protects you from paying 30k for a new car if u get in an accident or even possibly sued. House insurance protects you if your house is destroyed. 1250 dollars a year for a 500k home on average in NY. The ACA (affordable care act) insurance is different though....The healthcare exchange "bronze" model makes the insurance holder (patient) responsible for 40% of the bill - that would be 40k dollars - ouch - If I was a MD, I would be happy to have a hospital hire me and let them chase after the payment that is due. I am not an MD or a DO , but love having the ability to call my MD day or night weekend or holiday and having them come to any hospital I may be Admitted to, with them advocating for my care while I may not be able to do so.

    Medicine is changing - If you like choice... then maintain 'a Cadillac insurance plan - if u can '

    Oct. 09 2013 06:42 AM
    Mike from NJ

    I and dozens of my peers will not be accepting these insurance plans in northern NJ. The reimbursements are too low to even consider them. I will see less patients, but I will make more per patient by not accepting these insurances. In the end the patients I do see will be given more time and better care. Those practices accepting these plans will become mills, seeing patients for 3 minutes then out the door. Care will suffer.

    Best of luck to everyone signing up for these health exchange plans. I think you are being sold a worthless product. You are paying in to a debit card that will not be accepted at many places. But only time will tell. I hope the hospitals continue their fight.

    Oct. 08 2013 04:07 PM
    ellienyc from Manhattan

    I don't understand the reference to Aetna having NYPres as a choice. I thought Aetna had chosen not to participate in the exchange. Did they change their mind, or are you talking about Aetna non-exchange plans, like employer-sponsored ones?

    Oct. 08 2013 04:01 PM
    CVBlue from Somewhere in NY

    Yeah, I worked at NYUMC when managed care came to NY in the 1990s. Surgeons at NYUMC decided to opt out of any managed care insurance and only take the old-fashioned kind. That lasted a few months, until financial chaos insued as 1/3 of our ORs were idle. This will end the same way.

    Oct. 08 2013 12:32 PM
    Kathy from CT

    Can't figure out why a hospital would want to continue to have patients with NO insurance, for whom they get NO reimbursement, than at least get some payment.
    Federal law says patients can't be turned away from ER, so if the patient had a low-paying insurance plan, at least it's more than the hospitals would get now.
    Very strange.

    Oct. 08 2013 11:25 AM
    miguel from 06824

    You need to better police your content for hate speech, some of which has been blatantly.posted for this topic.

    Oct. 08 2013 09:35 AM
    Robert S from 07626 - Cresskill, NJ

    Obmacare may not present too much of a problem for getting into a Bronx hospital. But if you want Dr. Oz (prior to becoming a TV star, Oz was a leading New York heart surgeon) at NY Presbyterian to do your cardiac surgery, not likely to happen.

    Are you good at advanced math? The article describes eight hospitals each with a different number of insurers and different insurers who do or do not participate in all eight hospitals. Most of most of us are likely to struggle with the linear equations necessary to obtain the optimum solution based on insurers, hospitals, current ailments and future medical needs. E.g. if you are a poor gang member living in the Bronx and might be afflicted with puncture wounds in he abdomen then Montefiore is probably a good choice. However if you are an office worker with cholesterol issues then the optimal solution may not be so clear.

    All this and the enrollment website apparently has some fundamental design issues that will take time, talent and money to resolve.

    Oct. 08 2013 08:46 AM
    Tom Hunter from 10023

    Until now, providers have been able to charge ever-rising amounts for their services, making doctors, hospitals, Big Pharma and Medical Device Manufacturers the best paid in our entire economy.

    What these groups have failed to understand, though, is the end result they had been encouraging, which is a shift away from the "fee for service" model--which incented them to perform ever greater numbers of services irrespective of the alleged benefits of these services to patients--to a "fee for wellness" model that is now standard under the Affordable Care Act. Under the ACA, the incentives go in the direction that patients have always wanted them to be: doctors and their peers getting paid for keeping people well.

    Given that doctors have historically earned the highest salaries regardless of their quality or whether they were adding any new innovations to the market, they have no one to blame but themselves. A typical physician does not perform any special service, has not innovated or created any special advance that entitles them to such high salaries--as is the case in all other fields for the highest earners.

    To the hospitals and doctors who appear to whine that they're no longer going to be rich, I and others have no sympathy. What makes you so special? If you are an in network provider, you have a constant stream of customers sent to you by insurance companies. You have a license to print money and deserve to get your wings clipped. That is the future and you need to accept it.

    Oct. 08 2013 08:12 AM

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