Lunchtime Must-Read: Ann Marie Marciarille: Sutter Health vs. Blue Shield: War of the Gargantuas
The interaction of health-care regulation and antitrust policy is perhaps the most fraught area in the fight over how to build a system to control our health care costs. And not just individuals but the government has an enormous stake in this game–through exchange subsidies, and through all the other programs in which reimbursement rates are in any way influenced by what is customary and appropriate in the private marketplace:
…price transparency, and the promotion of [consumer] competition in health care markets. But when I see consumers whipsawed as with the current War of the Gargantuas taking place in Northern California, I wonder if consumer activation alone will save us. In order to have been a savvy purchaser of health insurance… you would also have to have known something about the health insurance and health care services contracting world. Can we reasonably expect consumers to master this, to ferret out what they really need to know?… Northern California employers have a fall open enrollment period…. Here’s what your employer (or exchange) surely didn’t tell health insurance shoppers… this past fall:
1. Blue Shield of California is a huge insurance company, with about three million covered lives in California.
2. Sutter Health is a huge health care provider with, for example, over 4300 licensed acute care beds in California.
3. They bargain fiercely right through and past the open enrollment deadline over the next year’s contract rates.
4. Even a behemoth such as Blue Shield… has, historically, been unable to bring Sutter to heel….
5. Decisions… [may be] made after the close of your open enrollment period….
6. The decision by a major provider to exit an established health plan after the close of the open enrollment period is apparently not deemed a qualifying life event allowing for special enrollment under Covered California….So the chat boards are lighting up. Can it be that a change in a health plan’s coverage options in a highly concentrated market such as Sacramento or the East Bay is not a a trigger for special enrollment rights? You mean you didn’t know all this already?
Watch out where Gargantua steps.