Patient advocates say the exclusion of one of Missouri鈥檚 top hospital systems from policies offered by the region鈥檚 biggest insurer under the Affordable Care Act could hinder treatment for some patients and force others to switch doctors.
The network for the Anthem BlueCross BlueShield plans, which will be sold through Missouri鈥檚 鈥淥bamacare鈥� marketplace, does not include BJC HealthCare and its 13 hospitals 鈥� among them Barnes-Jewish Hospital, the area鈥檚 premier academic medical center, and St. Louis Children鈥檚 Hospital.
Barnes Jewish Hospital in St. Louis, Mo. (Photo by Matt Hurst via Flickr).
鈥淭hat is a major concern for a lot of reasons,鈥� said Andrea Routh, executive director of the Missouri Health Advocacy Alliance. 鈥淐hildren鈥檚 Hospital, which in my mind is an essential community provider, is part of that network. If they鈥檙e not including the Children鈥檚 Hospital, care for children could really be compromised.鈥�
Anthem confirmed聽Wednesday聽that policies sold through Missouri鈥檚 online insurance marketplace, scheduled to open for enrollment聽Oct. 1, will not include BJC.
鈥淯nfortunately, we were not able to reach agreement with BJC,鈥� said Anthem spokeswoman Kim Ashley, adding that the insurer鈥檚 network was built for affordability and quality.
The plans are similar to 鈥渘arrow networks鈥� assembled elsewhere by Anthem and other insurers to bypass higher-priced health systems and offer more-affordable coverage. But consumer advocates worry tighter networks will disrupt care and limit access for middle- and lower-income consumers, many sicker than average.
With only one other insurer besides Anthem planning to sell policies through the exchange in eastern Missouri, the region will have some of the most limited choices anywhere under the health act鈥檚 marquee innovation, new federal data show. The other insurance company has not been identified.
Anthem recently briefed insurance brokers on its Missouri network.
鈥淲e knew it was going to be narrow but it surprised us鈥� about the hospitals left out, said Adam Berkowitz, a benefits consultant with Caravus. 鈥淚t was kind of eye-opening.鈥�
Joseph Pierle, CEO of the Missouri Primary Care Association, said his group鈥檚 community health centers serving low-income patients still don鈥檛 know whether they鈥檙e in Anthem鈥檚 exchange network.
鈥淣one of them had heard from Anthem,鈥� he said. 鈥淚鈥檓 telling everybody this is the biggest unknown since Geraldo Rivera opened Al Capone鈥檚 vault.鈥�
BJC, whose other facilities include Christian Hospital and Missouri Baptist Medical Center, is St. Louis鈥檚 biggest employer. BJC did not respond to a request for comment.
The health law created the marketplaces, also known as exchanges, to offer heavily subsidized coverage to individuals and families who do not have insurance through employers or government programs such as Medicare.
In 2011 Anthem聽聽in Missouri under its individual and family policies, many of whom are expected to seek care through the exchange because it will be more affordable. There were about聽聽in 2011.
The federal Department of Health and Human Services is running Missouri鈥檚 marketplace after state voters passed a measure prohibiting Democratic Gov. Jay Nixon from creating an exchange without legislative or voter approval.
Narrow networks present the opportunity for lower costs via discounts from select hospitals and doctors in return for patient volume. But smaller networks can require members to travel farther for care or make it hard to get appointments, patient advocates say.
鈥淚t means that the stranglehold that large hospitals have held over health insurance plans 鈥攖hat has kept them from reducing premiums 鈥攎ay be broken,鈥� said Timothy Jost, a law professor at Washington and Lee University and consumer health expert.
On the other hand, he said, 鈥渟ome of the plans are excluding essential community providers鈥� that are best equipped to deal with the problems of lower-income people.鈥�
Excluding key care providers from exchange plans has generated concern and complaints in other states.
Washington regulators聽聽four carriers from that state鈥檚 exchange, expressing concerns that their networks were too restrictive. All were eventually approved.
Maine regulators聽聽on Anthem鈥檚 intention to exclude some hospitals from its ACA marketplace plans. Anthem is the only insurer to offer policies next year on the exchange in New Hampshire, where it left聽聽out of the network.