MESSAGE FROM THE PRESIDENT

A PPO Exodus

Blue Cross Blue Shield of Illinois recently announced that it was eliminating its highly popular Blue PPO product from the insurance exchange.  Roughly 25% of Illinoisans, about 173,000 people, on Obamacare were in this plan that covered care at all academic tertiary hospitals. The Blue Choice PPO plan that replaces it does not cover care at Rush, Northwestern, University of Chicago, and NorthShore. These choices have been taken away from many people with serious chronic illnesses, including 82 people awaiting kidney transplants at Rush University, according to CMO David Ansell. He worries if or where these patients will be able to get their transplants. And there is an obvious loss of continuity of care inherent in this change.

Taking care of sick patients is expensive. In 2014, BCBSIL took a $280 million loss. Blue Cross states that it underestimated the amount of expenditures by its health exchange clients. But it’s not surprising when you consider that many were previously uninsured due to a pre-existing condition or unaffordable costs. Now these patients are catching up on their health care needs. Sadly, it’s possible, even likely, that Obamacare PPO plans may disappear in the future. For 2016 there are 12% fewer health plans being offered on the federal exchange, with the number of HMOs increasing and the number of PPOs decreasing by 40%. It remains to be seen whether insurers can continue to operate PPOs without taking a loss.

Even if you’re in an employer-based PPO or HMO, you may get hit with unexpected costs due to what’s called a “narrow network.” The insurer chooses which providers are in your network and covers their services accordingly. However, sometimes it’s not exactly obvious just who is covered. For example, a good friend of mine was recently admitted to his in-network hospital for a stroke and is, thankfully, fully recovered. Upon discharge, he was given a 30-day cardiac monitor that was provided by an out-of-network company. He didn’t know that, his doctors didn’t know that, and he was left with a $7,000 bill. No one warned him of the cost, nor did he have any ability to “shop around” for an in-network provider. When you’re sick, you’re not exactly in the best position to be an informed consumer.

How do we help protect our patients from unforeseen costs? We can provide feedback to insurance companies when there are gaps in coverage. We could also seek to mandate minimum requirements for narrow networks. New York’s “Surprise Bill Law” could be a model for Illinois. It protects patients from out-of-network fees when they receive emergency care, when there are no in-network providers available or when there are no disclosures made to the patient prior to the service. Providers and insurers would dispute fees through an independent agency. The law also creates network adequacy requirements for insurers to follow.

The Chicago Medical Society is working with insurance companies to increase access to tertiary care and improve their network design. We would like to hear about your experiences with narrow networks, and ask that you share them with us. We plan to also work with the Illinois State Medical Society to help create a law in Illinois. Please support our efforts in this and other important initiatives by recruiting your colleagues to become members. Our voices are stronger when they are many.

Kathy M. Tynus, MD
President, Chicago Medical Society