October 10, 2009

Health care activists confront Horizon BCBSNJ Executive Tom Rubino outside Horizon headquarters in Newark NJ.

I was interested in this story, not the least because, well, this is my COBRA carrier and Horizon's crazy reimbursement rates are the reason why my doctor was kicked out of their network. But really, it could be anybody's insurer. (Oh, and please: If you're having a problem like this with an insurer, call your congressman's office. They usually have a staffer who does nothing but handle insurance problems for constituents.)

BAYONNE, N.J. -- One February morning, a courier arrived at the front desk of Bayonne Medical Center, trying to get to a patient's bedside. His mission: to deliver a letter from New Jersey's dominant health insurer warning that the patient would face a huge hospital bill if he did not leave right away.

Hospital security guards stopped the courier -- and 13 others who came soon after -- before they reached patients' rooms. But then came the faxes and, after that, the letters mailed to patients' doctors and homes. Told that her health plan would not pay for her to stay in the hospital, a 35-year-old social worker named Lisa with a severe lung infection was so unnerved that, tethered to an IV pole dripping antibiotics into her arm, she began to pack her gym bag before a staff member coaxed her back into bed.

The hardball tactics being used to pry patients from their sickbeds illustrate the colliding financial interests that pervade U.S. health care. It is a tug of war over where patients are treated, who decides how much care they receive and -- fundamentally -- which parts of the health-care industry gain or lose when people become ill.

The battle playing out in Bayonne has particular relevance as Congress tries to rewrite the rules that govern health care nationwide -- with hospitals, insurers, doctors and other stakeholders descending on Capitol Hill to angle for advantage. The bills before the House and the Senate would shift the system's balance of power that has evolved over decades -- a balance at the core of the dispute here.

Yet the fight over hospital patients in this working-class enclave also hints at the limits of what federal health-care changes would accomplish; none of the bills would legislate away the specific business practices that have escalated into a full-scale brawl between the city's only hospital and New Jersey's largest health insurer, Horizon Blue Cross Blue Shield. Lawsuits are flying in both directions, each side accusing the other of fraud, greed and underhanded behavior that harms consumers and increases medical costs. Bayonne accuses Horizon of harassing patients and not paying its bills. Horizon accuses Bayonne of price-gouging and interfering with its health plans.

Such a sharp clash of self-interests is evidence that President Obama may have been naive in suggesting early on that health care's stakeholders are now willing to set aside rivalries that have thwarted previous attempts at reform, said Uwe E. Reinhardt, a health economist at Princeton University who led a state commission on New Jersey's shaky hospital finances. "It's no different from Iraq with all the different tribes. . . . 'How does it affect the money flow to my interest group?' " he said. "They are all sitting in the woods with their machine guns, waiting to shoot."

In such a tense climate, Bayonne has become virtually the only hospital in the country that has withdrawn in protest from the "provider networks" of every major insurer, abandoning a tradeoff that has become a staple of the health-care system: Hospitals agree to be paid lower rates in exchange for knowing that insurers will steer patients to their beds. Bayonne is not, however, the only hospital at odds with Horizon. Four others have pulled out Horizon's network or are close to leaving.

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