April 17, 2010


This isn't a new idea, and it's not limited to Massachusetts. (When I first read about it, it was called "tiered" coverage.) I expect we're going to see it spread, though, because the just-passed federal legislation doesn't actually reform the health care system, and much of the much-vaunted "access" is in name only.

Which means the fight isn't over. Because if you have a serious health problem and your coverage will send you to the facility that doesn't have such a great track record, you're out of luck:

Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals such as Massachusetts General and Brigham and Women’s — a once radical idea that is gaining traction as a way to control soaring health care costs.

Governor Deval Patrick and Senate President Therese Murray have included such restricted provider networks in their recent legislative proposals to control rising insurance rates. And the state this month began offering limited-network plans to 300,000 state employees, retirees, and their families, promising 20 percent discounts on premiums if they are willing to give up access to some of the Boston area’s most renowned hospitals.

Dolores Mitchell, executive director of the agency that oversees health insurance for state employees, said she wants “to send a message to the more expensive [provider] organizations that, ‘Hey, we’re not going to just sit still and do nothing’" as medical costs climb year after year.

But even as state officials promote the idea, there are obstacles to its wide adoption. Some of the state’s largest insurers have contracts with powerful teaching hospitals and doctors’ groups that could make it difficult to exclude them. And Massachusetts consumers and employers have long cherished choosing from a broad range of providers.

In a yearlong investigation into rising health care costs completed last month, Attorney General Martha Coakley cited "distorted" contracting practices as one factor. She found that providers with market clout have negotiated clauses in their contracts that prohibit or inhibit insurers from creating plans intended to steer patients away from them. She did not name the companies involved, but said regulators and lawmakers should move to discourage or forbid these practices.

Certain providers “are strong enough to dictate which products get into the market," agreed Rick Weisblatt, senior vice president for health services at Harvard Pilgrim Health Care, the state’s second largest insurer.

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