Thinking About Health: How insurers restrict health care choices

Farm Forum

Should you be able to choose your own doctor? Most people would say yes, and for years letting patients choose their providers was an almost sacred requirement for any health reform proposal.

But political talking points in the heat of a legislative battle are one thing. Reality is another, and today’s reality is you cannot always choose the person you want to treat you.

The change is part of what I like to call the Great Cost Shift accelerated by the Affordable Care Act which, thanks to compromises made as the bill was negotiated, includes few effective cost controls to slow down medical inflation. More fundamentally, the shift stems from our apparent unwillingness as a country to allow government to negotiate prices with health care providers as other nations do.

The Affordable Care Act, for example, prohibits Medicare from negotiating prices for drugs available to beneficiaries under the prescription drug benefit. Yet many experts say that would save money for Medicare as a whole.

Since controlling costs the way the rest of the world does is taboo, the remaining option is to put the burden on consumers when they buy health insurance and patients when they use health care services. Right now the tools for doing that are narrow networks of providers.

Insurers allow in their networks only providers who agree to accept the fees insurers are willing to pay. Typically, insurance carriers have tried to lower those payments claiming that helps bring down medical costs. It also has triggered fights across the country between hospitals and insurers such as the one that raged this summer between Catholic Health Initiatives, which runs 12 Nebraska hospitals and Blue Cross Blue Shield, the state’s largest carrier.

As this fall’s open enrollment approaches you’ll bump against this dilemma: Do you choose a policy with a narrow network, possibly disrupting your care, and leaving a trusted physician in return for cheaper coverage that goes along with those restrictions? Or do you spend more for higher-priced coverage and the freedom to choose the providers you want, including some super specialist you might need?

If there are few insurers selling coverage in your area, the decision is especially tough.

It goes back at least two decades to the time insurance companies promised that managed care would save the system from escalating costs. Under managed care, the insurers restricted the doctors and hospitals they would cover, and patients howled all the way to their state legislatures. In many states lawmakers passed “any willing provider laws” making it easier for patients to pick their doctors. Sometimes women could pick a favorite gynecologist or someone with a chronic condition could select a specialist as a primary care doctor and navigate around the restrictions.

There’s a new push these days for “any willing provider” laws. In November South Dakota voters will decide if any provider can join an insurer’s network if the provider agrees to the carrier’s terms and conditions and practices within its coverage area. The ballot measure, backed by the South Dakota Medical Association and specialty hospitals, would eliminate insurers’ restrictions on who can be in their networks. Both sides are expected to spend big bucks to try to win the public to their side.

In earlier battles insurers maintained they chose for their networks only providers who delivered high quality care. Some still say that. I am highly skeptical of those claims. Quality measures especially for doctors, some devised by government, some by for-profit and not-for-profit groups, are not great. These fights are still about money, not high-quality care. The biggest casualty is still the consumer.

Editor’s note: These columns, which focus on rural health issues, are funded by a grant from The Commonwealth Fund and distributed through the Nebraska Press Association Foundation, the Colorado Press Association and the South Dakota Newspaper Association.