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With health insurers and hospital chains in the US saving on contracts, patients can suffer: shots



California's Anthem Blue Cross, one of the state's largest health insurance companies, is now battling with Sutter Health over how much it should pay for the company's 24 hospitals and 5,000 doctors in Northern California to treat tens of thousands of patients.

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California's Anthem Blue Cross, one of the state's largest health insurance companies, is now battling with Sutter Health over how much it should pay for the company's 24 hospitals and 5,000 doctors in Northern California to treat tens of thousands of patients.

David McNew / Getty Images

David Lerman, a lawyer in Berkeley, California, changed health plans this year to learn that his new insurer has no contract with his community's main insurer.

Anthem Blue Cross of California, one of the state's largest health insurance companies, is struggling with Sutter Health about how much they need to pay for the care of tens of thousands of people who assure them in Northern California. Sutter operates 24 hospitals in the region and lists around 5,000 doctors on its network.

"I do not think I thought I would buy the entire Sutter network – this is the biggest game in Northern California." Network, "says Lerman, whose family is reassured by his wife's job as a professor at California State University.

Lerman and his Family Attending a Blue Cross Anthem enrolled PPO can continue to visit Sutter until the middle of the year, even if a new contract is not signed, fortunately nobody in his family is suffering from a chronic illness, but he does not know which providers will ultimately be included in his health plan network. Contract disputes between insurers and health care providers have long been an integral part of the national healthcare industry, but the stakes have risen as major players on both sides have grown to gain market share and influence network negotiations.

The Most negotiations are completed before the al contract expires and consumers usually do not hear about it . the scenes disagreements. However, if insurers and providers fail to reach agreement in time, patients may be forced to pay higher care rates that are no longer included in their health plans. At least this can lead to significant fears.

"It's a game with chickens, and at the end of the day somebody winks and they come to an agreement," says Wendell Potter, a former senior health insurance executive from Cigna, an industry critic and a strong advocate of comprehensive health care reform ,

"The big losers are patients," says Potter, "because there's a time of insecurity and anxiety – and there's a chance The doctors and hospitals you're trying to go to are no longer on the network." [AnthemSaysThatManyHospitalsintheHospitalAreNotInvestigating”/>

Amy Thoma Tan, a Sutter spokeswoman, in an email saying, "We are in active negotiations with Anthem Blue Cross and acknowledge that a timely agreement – which protects access and choice – is in the best interests of our patients, employers, hospitals and clinicians. "

A statement by Eric Lail, an Anthem Blue Cross spokesman, also missing details:" How? When negotiating with vendors, we try to strike a balance between protecting affordability and providing a broad network of vendors to make decisions that take time can.

Sutter has been accused of having used his regional market for the financial benefit because of the high price he paid for. "When large hospital systems merge with competitors and medical practices converge," it is much harder for insurers to say, "Okay, we'll let you go, "says Sabrina Corlette, research professor at Georgetown University's Health Insurance Reform Center

Corlette says both sides should now have a greater incentive to come to an agreement.

"If you have a big, giant health system and a big giant payer with tens of thousands of inscribed lives, the incentives to do that will work out a little bit, in private much more," she says. "The risks of [public relations] are so high for both parties."

Other states have seen their enmity between health systems and insurers.

Judy Hays, a retiree living outside of Pittsburgh, has a rare form of leukemia. She is involved in a feud between two regional health giants among many patients. She plans to change the doctor because she wants to keep her insurance.

Courtesy of Judy Hays


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Judy Hays, a retiree living outside of Pittsburgh, has a rare form of leukemia. She is involved in a feud between two regional health giants among many patients. She plans to change the doctor because she wants to keep her insurance.

Courtesy of Judy Hays

In West Pennsylvania, as of July 1, nearly 50,000 people receiving Medicare care plans from Highmark Health will lose access to hospitals and doctors at the University of Pittsburgh Medical Center, as the two regional health giants are slow divorce.

One of these patients is Judy Hays, a 75-year-old retired office manager from Crescent Township, Pittsburgh, who relies on UPMC's doctors and hospitals to treat her rare form of leukemia. Now she wants to change her doctor because she wants to keep her insurance, which has paid for her expensive medication.

"It's very tough, these people have been looking after me for nine years, I can not interrupt my care," says Hays. "I'm very angry about that."

In Georgia, WellStar Health System plans to accept the two companies with eleven hospitals and numerous medical practices, the individual policyholders of Anthem on February 4, not more than in-network patients. [2017] In 2017, a deadlock between Anthem and the Connecticut Hartford HealthCare system forced hundreds of thousands of patients to leave the network before the two parties had a deal. The patients' bills were treated retroactively as in the network so patients did not suffer financially.

However, "there were stories of people who had to cancel operations and switch providers," says Ted Doolittle, Connecticut's health care prosecutor. "There were all these fears and disturbances."

Under pressure from their voters, Connecticut lawmakers passed a law last year that allowed consumers to receive network pricing for 60 days during contract disputes. The new law is "an improvement," says Doolittle, who called on legislators to pass such legislation.

In the current California dispute, Anthem Blue Cross members with PPOs will be able to use Sutter doctors and hospitals for in-network rates over the next six months says Thoma Tan, the Sutter spokeswoman. People with HMOs are faced with more insecurity.

Lail, spokesman for Anthem Blue Cross, says the insurer's clients "can continue to see their Sutter caregivers for the time being as these negotiations continue." According to state law, Anthem Blue Cross has informed patients with Medicare and Medi-Cal HMO plans that they could be reassigned to other non-Sutter providers, says Lail.

There are exceptions that allow pregnant women to be very young Thoma Tan says children and some other patients should continue to be provided with Sutter's in-network tariffs, regardless of the type of insurance they have at Anthem Blue Cross.

Sutter has argued with other insurers, including the Blue Shield of California In a dispute, around 270,000 consumers were affected before the two sides came to a deal in February 2015.

Sutter's dominant position in California and its high prices for in-patient care have long been criticized. One patient reported that Sutter had billed $ 1,555 for a 10-minute visit to the emergency room to treat a cut finger, including $ 55 for a gel bandage and $ 487 for a tetanus shot.

Last year, State Attorney General Xavier Becerra sued the police for a huge health care system claiming it had unlawfully overwhelmed patients and displaced competition in California. Sutter has argued that Becerra has exceeded his authority and that limiting Sutter's ability to bargain with insurers harms consumers.

Anthem Blue Cross, which assures hundreds of thousands of Californians, and whose parent company Anthem achieved a profit of $ 3.8 billion in 2017. has also drawn the wrath of the state regulators. The Managed Health Care Department fined the insurer for $ 5 million in 2017 for failing to respond to consumer complaints in time. Previously, the state received a $ 6 million fine against Anthem Blue Cross for violating the consumer system complaint system.

In Berkeley, Lerman wants only that Anthem and Sutter break up their differences to give his family access to the most comprehensive insurance options

"As a consumer, is there not a place to go and not worry about that you are not insured? " he is angry "If I am ill, will I go to the local hospital – or to the airport and fly to Europe?"

This story was produced by Kaiser Health News which published [California Healthline] an editorially independent service to the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.


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