A 96-year old patient recently arrived at my office in Monroe and burst into tears, saying her insurance company called to tell her she needed to switch doctors. She brought a letter indicating that I would no longer be in-network for her Medicare Advantage plan with Horizon Blue Cross Blue Shield.
The state’s largest carrier had excluded from its new Medicare Blue Advantage plan physicians like myself who aren’t affiliated with hospitals in its contested Tier 1 OMNIA preferred network. I am a geriatrician in a practice affiliated with Saint Peter’s Healthcare System, whose hospital in New Brunswick has been given Tier 2 status by Horizon.
Saint Peter’s University Hospital is among those suing Horizon over the creation two years ago of it's OMNIA Alliance, which largely excluded independent hospitals in favor of large multi-hospital systems. Saint Peter’s argues that this latest salvo – dropping many doctors from one of its more affordable plans and excluding Saint Peter’s from participating in its Medicare Blue Advantage network – is part of a concerted effort to squeeze out independent hospitals as the insurance giant seeks to restructure health care, and maximize profits, in New Jersey.
But back to my patient. Because she came in during the open enrollment period, which ends December 7, my staff helped her find a comparable plan with another carrier that allowed her to remain with our practice. She was greatly relieved, as was I since continuity of care is especially important for the elderly who may have complicated medical histories. But I remain concerned for other seniors who, based on the letter from Horizon, may believe they have no option but to give up their doctors and the hospitals they prefer. My patients in a local nursing home who likely will have had little awareness, much less a say, as their insurance plan funnels them away from the doctor and/or hospital of their choice.
A physician for 16 years, I am board-certified in internal medicine, geriatrics, hospice and palliative care. I am one of a limited number of geriatric doctors serving a growing elderly population of elderly patients. Here in Middlesex County, there are very few geriatricians now included in Blue Advantage plan. It is uncertain whether my patients who stay with the plan will be able to get timely appointments with an in-network geriatrician nearby. Why would Horizon limit access to a specialty in short supply?
The area hospitals in the OMNIA network may provide good care, but so does Saint Peter’s and its doctors who have been excluded. As far as we can tell, the exclusion was not made on any data relative to patient care. In fact, Saint Peter’s was not even given an opportunity to apply for participation in the plan. My own efforts to speak about it with Horizon on behalf of my patients were rebuffed.
Many of my patients have a decades-long attachment to Saint Peter’s. The healthcare system offers top-notch medicine – its stroke care, for example, is recognized as superior. But its appeal extends beyond clinical excellence. My patients of all faiths are choosing the Catholic hospital because it’s a kinder experience for them, offering individual, loving attention and outstanding nursing. They tell me they feel “lost in the sauce” in the “big box” network hospitals. The exclusion of Saint Peter’s and its doctors limits choice for some of the most one of our most vulnerable patients.
Saint Peter’s President , Leslie Hirsch, has been joined by CEO's of other excluded hospitals in calling on state lawmakers to hold hearings on Horizon’s tactics in this latest attempt to steer patients to its preferred hospitals and doctors, and its overall efforts to restructure health care. Navigating the complicated world of health insurance can be difficult and confusing, more so for elderly and infirm patients. There is still a short time left for open enrollment, when healthcare consumers can opt for a comparable plan that includes the doctors and hospitals they prefer. Horizon insures more than 40 percent of the state's population and wields considerable clout but its aggressive efforts to limit care choices should not go unchecked. Our patients deserve better.
Dr. Erinn E. Beagin is a board-certified geriatric specialist with Saint Peter’s Physician Associates in Monroe.
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