AMCs React to Being Shut Out of Some Exchange Plans

Cheryl Clark, for HealthLeaders Media , December 13, 2013

The situation in Detroit, Conroy says, is such that people enrolling in the exchanges are getting into plans requiring them "to drive over an hour to get to a facility where they would be covered in network."

Sarah Lechner, general counsel for the New Jersey Hospital Association, echoes similar woes.

"It's difficult to say exactly how this will play out here after Jan. 1, but we do have serious concerns about the impact on providers," she said in an e-mailed statement.

"Payers essentially are forcing hospitals into networks based on existing commercial contracts and not always engaging in rate negotiations. Any further squeeze on hospital revenues raises very real worries about hospitals' ability to carry out their mission – obviously the mission to provide care including to the uninsured, but also the ability to continue quality improvement initiatives, community benefit [activities] and to provide teaching and research in academic medical centers."

Officials for America's Health Insurance Plans declined to comment, saying they can't speak for individual contracts between plans and providers. Instead they referred readers to AHIP blog posts that say consumers and employers prefer smaller provider networks over higher premiums.

Seattle Children's Hospital
Many academic medical centers, Conroy says, are watching what happens to Seattle Children's Hospital, where Senior Vice President and Chief Strategy Officer Sandy Melzer, MD, says his 325-bed hospital has not been able to participate in products offered by three of the six health insurance companies in Washington State, and has sued the state for allowing the hospital's exclusion.

The situation means that parents of these children—knowingly or perhaps unknowingly—are buying plans that will mean half will not be able to get the specialized care available only at Seattle Children's, which is set up for complex cancer, trauma, heart, and other types of specialty care not available at surrounding community hospitals, Melzer says.

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