Buy a new health insurance plan after Tuesday and you could notice something big is missing.
St. Rose Dominican Hospitals, Southern Nevada’s only Catholic, not-for-profit hospital system and the dominant hospital group in the southern Las Vegas Valley, is being left out of some new plans designed to comply with the Affordable Care Act, or Obamacare.
Aetna is rolling out a new HMO that will include only hospitals in the Valley Health System and HCA Healthcare. Meanwhile, a big carrier selling on the new Silver State Health Insurance Exchange, which launches Tuesday, will have just three local hospitals in its plan, none of them in the St. Rose system. In fact, there aren’t any “premier” hospitals in the network, Michael Caparso, cofounder of local employee benefits firm National Healthcare Access, said earlier this month.
If you already have coverage with St. Rose in your network and you’ll keep your plan after January, the system should still be an option for you. But if you’re one of hundreds of thousands of uninsured Southern Nevadans and you’re buying a plan for the first time, you might not be able to visit the system for a non-emergency without paying most or all of the cost.
Aetna spokeswoman Anjanette Coplin said the company won’t say why some hospitals are in and others are out of some smaller-network plans.
But Rick Krause, vice president of employee benefits for Las Vegas insurance broker Kaercher Campbell and Associates, said when insurers pare hospitals, clinics or physician practices from networks, it’s often because of cost.
“It’s not an uncommon practice to cut out more expensive providers,” Krause said.
It’s especially going to be the case with networks in exchange-based plans, he said, because the exchange is designed to make coverage affordable for individual buyers. Shrinking the network is one way to keep new, mandate-laden plans accessible.
Krause added that he didn’t have details on what St. Rose Dominican charges for its services, but he said the hospital system has “typically always maintained a higher price point than others.
“They have gone through contracting, negotiations and debate with virtually every carrier in town for that reason,” Krause said. “It’s usually a process (insurers) go through to try to get back to what’s considered a more reasonable contract amount based on the services provided. The hospitals will argue that they provide much greater service, or have a smaller incidence of readmission. There are two sides of the equation to take into account.”
In a statement, St. Rose officials didn’t address costs or reimbursement issues. Instead, they said they support the Affordable Care Act and its programs to lower costs and expand coverage.
“While we had hoped private health insurance plans would elect to include St. Rose in individual plans they have developed to offer via the state health exchange, we support expansion of coverage regardless of how many plans include our hospitals,” the company stated.
The statement also said St. Rose would continue to be in “dozens” of existing off-exchange plans and would stay in Medicare and Medicaid networks. And the hospital system will dedicate part of its website — www.dignityhealth.org/enroll — to listing individual insurance plans that include St. Rose in their networks.
It’s not just hospitals disappearing from networks; some physicians are feeling the pinch, too, as insurers increasingly contract with a single large practice rather than hundreds of smaller offices.
“A lot of my clients say, ‘Great, we can apply for a subsidy through the exchange and lower our premiums a little bit,’” said Phil Randazzo, owner of Las Vegas insurance brokerage Nevada Benefits. “Then they look a little deeper and see none of their doctors are in their network. People are looking at switching physicians they’ve had for 15 years to save $40 a month on premiums.”
Randazzo said he doesn’t know if doctors are removing themselves from networks because they don’t like insurers’ proposed reimbursement rates, or if carriers were leaving out physicians because the docs wanted too much money.
“You can’t reimburse the physicians too much if you’re not collecting enough in premiums,” he said. “Basically, I think it all comes down to money for the networks. It always has.”
Even if higher-end providers hang on within non-exchange networks, the Affordable Care Act could force long-term changes in health care that affect how hospitals in particular operate, Krause said.
There are more than a dozen acute-care hospitals in Las Vegas, all of them scrambling to offer the same services, from orthopedic surgery to cardiovascular procedures. That may have to change due in part to the new, smaller networks, because hospitals left out of plans may have to specialize to attract customers.
That wouldn’t necessarily be a bad thing, Krause said.
“Right now, every hospital tries to be everything to everybody. They all have to pay for the cost of purchasing the same equipment,” he said.
Instead, hospitals could specialize in, say, pediatric intensive care, or cardiac health.
Contact reporter Jennifer Robison at email@example.com. Follow @J_Robison1 on Twitter.