Patients who have Anthem Blue Cross Blue Shield health insurance and usually see doctors at Mount Sinai in New York City have been in a bind since the start of the year due to a contract dispute.
Mount Sinai doctors went out-of-network for Anthem members in January, meaning patients had to pay more or look elsewhere for care. The health system later said their doctors were back in-network, only to report on Wednesday that this was not the case, and blamed Anthem for the stalemate. The insurer released its own statement blaming Mount Sinai.
Elisabeth Benjamin, vice president of health initiatives at the nonprofit Community Service Society, an anti-poverty group, discussed the controversy earlier this week with “All Things Considered” host Sean Carlson.
Here’s a lightly edited transcript of their conversation.
Can we just start with the relationship between big health insurance companies and health systems? It kind of sounds like a bit of a clash of titans here.
Elisabeth Benjamin: It’s exactly the analogy I always use, and patients are just the little people at the feet of the titans that get kind of stomped on.
In our country, we really elevate free market health care and we allow contracting norms to kind of rule health care. That works great for the big parties at stake, the hospital systems and the insurance companies, but it doesn’t work for patients.
And why is that? We are locked into what’s called open enrollment periods. That only happens over a couple of weeks, typically at the end of the year. We have to make our decisions for the entire year based on what we think is going to be where our doctors are. Usually, people base their decisions on two things: price and where your doctor is.
Unfortunately, many of these big things happen after the close of open enrollment, which is really unfair for patients. And, so in this case, it happened actually right before open enrollment. So some people did get notices in advance and could make decisions. But if you have job-based coverage, it’s not like you can switch to another insurance company. You only have Anthem, right? You’re just stuck.
So it’s a huge problem. It’s in every corner of the health insurance industry. It doesn’t matter if you have Medicare, Medicaid, job-based coverage. You are impacted by this terrible system. An enormous number of people are impacted.
What are the sticking points of the Anthem-Mount Sinai dispute? Of course, we can imagine that it’s about money, but what are the key differences?
It’s always about money. I mean, occasionally, a provider will be terminated from a health plan for fraud or misconduct. Very rare.
The big four hospital systems in New York City tend to charge anywhere of 400%, 600% of the Medicare rate. And the carriers whose job it is to control costs are supposed to negotiate down from those prices to get a more reasonable cost. They’ve failed utterly.
In New York state, we have the second-largest expenditures on health insurance in the country, and the biggest component of a health insurance premium — what it’s spent on — is hospitals. And so our hospitals have incredible market power.
My colleague Caroline Lewis, who covers health in the WNYC newsroom, spoke with a patient who has a chronic blood disorder. She said all her specialists are at Mount Sinai, and this has been pretty disruptive for her. Are you hearing those kinds of concerns?
Every day. I just want to point out that people do have a three-month grace period, if you have a chronic condition, under the New York State Patient Bill of Rights. That’s not much. As with this woman, three months, what does that get her? Nothing.
Blue Cross Blue Shield and Mount Sinai aren’t the only ones in a contract dispute. More and more New Yorkers are finding themselves in a limbo like this. UnitedHealthcare and NewYork-Presbyterian are also in the middle of a contract dispute right now. What’s behind this? Is it consolidation in the health care industry?
Yes. Consolidation is a huge problem. We’ve lost 53 hospitals in New York state over the last two decades, so that means there’s more market power vested in the hospitals.
But quite honestly, I think this is really the byproduct of a free market system. If the government is going to abdicate its responsibility to regulate health care, then this is what you get. You get free market chaos.
What can patients actually do? How much leeway do they have when they want to stick with the doctor who is considered out-of-network now? Or do they just have to stick through it and wait for a resolution?
Yeah. Or they can try to find a new doctor and ask their current doctor to give them a recommendation of someone else at the new hospital system that they’re going to have to be part of.
Right now in New York state, we have a 60-day cooling-off period in these contract disputes where the carrier will notify you that there’s this contract dispute, and they’re supposed to resolve in 60 days. Gov. Kathy Hochul has proposed to extend that to 120 days.
Now, there’s something called the No Surprises Act. It took effect in 2022. It offers protections for some patients whose providers drop out of network due to a contract dispute. People getting treatment for serious conditions can keep their in-network rates for up to 90 days, with the current providers delaying the need to find a new owner facing higher rates. What about regular patients?
Well, first of all, that’s great if your provider’s willing to keep accepting the current rate, but that’s what the dispute’s about. So if your provider isn’t willing to keep you for those 90 days, you’re really at the whim of your provider.
When one of my providers went out recently out-of-network, she refused to keep me on. I had a chronic condition. She wasn’t going to keep me at the in-network rate. That’s why she was leaving the network. It wasn’t good enough.
And so it doesn’t really protect patients as much as you would like.
What policy reforms do you want to see to help patients in these kinds of disputes?
Well, I think that our lawmakers should really step up and say we have to have a standardized contracting calendar. All these contract disputes must be resolved by October of the year.
Networks must be established by Oct. 1, and then they have to abide by those contracts, with the exception of fraud or misconduct, for the following calendar year. That’s the only solution that actually works for patients and is fair to everybody.