Hospital contract void

HealthOne no longer 'in network' for United Healthcare

Bill Scanlon, Rocky Mountain News

Friday, September 1, 2006

Hundreds of thousands of Coloradans must find a new hospital or pay significantly more for care as a midnight Thursday deadline passed in a dispute between the state's largest health insurer and its largest hospital company.

Health and government officials Thursday urged Denver-area residents not to panic over failed contract talks between insurer United Healthcare and HealthOne.

There are plenty of alternatives and exceptions that should make the situation inconvenient rather than disastrous, Colorado's insurance commissioner and a spokesman for United Healthcare said.

United Healthcare and HealthOne are at an impasse over the amount the insurance company will reimburse hospitals for their services.

The result is that 800,000 Coloradans insured by United Healthcare, PacifiCare and Secure Horizons will have to pay higher prices if they check into HealthOne hospitals or its 10 ambulatory centers. Those centers, as of today, are no longer in the United Healthcare network.

Late Thursday, state Insurance Commissioner David Rivera said he and United Healthcare agreed on a plan that encompasses certain exceptions and also stipulates that if policyholders don't have reasonable access to health care, United Healthcare must accommodate them at a HealthOne facility at no extra cost to the patient.

"While I'm disappointed that it appears both sides will not come to an agreement by the deadline, the contingency plan we've put in place will help mitigate disruptions to consumers," Rivera said.

He and Gov. Bill Owens will continue to monitor the situation.

About 40 percent of metro Denver residents with health insurance are covered by United Healthcare or its subsidiaries, PacifiCare and Secure Horizons.

And 40 percent of the hospital beds in metro Denver are owned by HealthOne hospitals.

Still, nearly all metro-area doctors have privileges at hospitals other than the seven in the contract dispute with United Healthcare, they said.

According to United spokesman Tyler Mason, just 50 of the 4,500 metro-area doctors have privileges only at HealthOne hospitals.

If a member of PacifiCare, Secure Horizons or United Healthcare goes to a hospital "out of network," it can increase significantly the cost to the patient.

But because most doctors have privileges at more than one hospital, the disruption should be minimized, the insurer said.

If someone insured by United Healthcare has back surgery scheduled with a doctor at Swedish Medical Center, for example, that doctor likely can schedule the surgery at another hospital outside the Health- One system - although it's likely the procedure will have to be postponed for several days or weeks.

Rivera said Thursday one of the hospital chains in the area is expediting paperwork so doctors can gain privileges in about seven days. Other hospitals are taking longer to approve but still are getting it done more quickly than the typical 30 days.

Still, dozens of doctors scrambled Thursday to get privileges at alternate hospitals as both sides in the negotiations between HealthOne and United Healthcare said there was virtually no chance that a contract would be reached by the midnight deadline.

Members already checked into a HealthOne hospital for treatment will be treated at the lower "in network" rates, said spokespeople for both sides.

Also, people with end-stage renal disease, as well as those with AIDS and certain cancers, will continue to get treatment at the lower rates.

And women in their third trimester of pregnancy will continue to get the discounted rates.

State law requires that all licensed insurers have adequate "in-network" sites for their members.

If Rivera isn't satisfied with the plan, he'll revert to an order that gives him authority to enforce a plan the state finds acceptable.

Rivera said United Healthcare has a well-thought-through plan to ease disruptions, but that there are still areas that need clarification.

What is clear, Rivera said, is that in an emergency, all United Healthcare members can go to the nearest hospital and receive the lower "in-network" rates.

The contract dispute affects hospitals, not doctor's offices, he noted. Members will keep the same benefits for checkups and other doctor's office visits and won't have to change physicians.

HealthOne spent Thursday alerting patients and doctors about what to expect, spokeswoman Linda Kanamine said.

"If you have surgery scheduled, that's stressful enough," Kanamine said. "We don't want to add to that. Our focus is on doctors and patients, to make sure they're accommodated as they need be."

United Healthcare says it is offering to increase reimbursement rates for hospital procedures by a percentage "in the single digits."

HealthOne says that's not enough to meet rising costs and would equal a reimbursement rate lower than those agreed to by all the other major insurers.

But United Healthcare spokesman Mason said its duty is to try to keep down premium costs for employees and employers.

"We still feel as strongly as ever that if we accepted a rate increase they are asking for, that would be directly opposed to our objective of making health insurance affordable in metro Denver."

Even a single-digit increase "will price quite a few people out of health insurance altogether."

United Healthcare is the nation's largest health insurance company, and HealthOne, a subsidiary of Healthcare Corporation of America, is the largest hospital company in the U.S.

The two companies are locked in a similar conflict in northern Florida, where their contract expired Wednesday.

Mason said there are plenty of vacant hospital beds in metro Denver outside the HealthOne system and "with rates more in line with the marketplace . . . and with comparable or better quality."

U.S. Sen. Ken Salazar, D-Colo., on Thursday called on both sides to redouble their efforts to reach an agreement, citing the disruption to the lives of Coloradans.

State Sen. Bob Hagedorn, D-Denver, chairman of the Senate Health and Human Services Committee, and Rep. Anne McGihon, D-Denver, chairwoman of the House Health and Human Services Committee, sent a letter to the governor, urging him to bring both sides together and arbitrate, if necessary, to resolve the impasse.

The impasse

• At issue: The amount of money hospitals will be reimbursed for treatment of policyholders of United Healthcare, PacifiCare and Secure Horizons

• The insurer: United Healthcare says HealthOne hospitals ask for higher reimbursements than other hospitals.

• The hospital: HealthOne says United Healthcare wants lower reimbursements compared with other insurers HealthOne contracts with.

• Who is affected? Those insured by PacifiCare, United Healthcare or Secure Horizons and who are in need of inpatient hospital care or outpatient surgery

• Which HealthOne hospitals are affected by the dispute?

Rose Medical Center, Presbyterian/St. Luke's Medical Center, Sky Ridge Medical Center, North Suburban Medical Center, Swedish Medical Center, Medical Center of Aurora, Spalding Rehabilitation Hospital and HealthOne's ambulatory care centers

• What if a patient is already in the hospital? They will continue to get "in-network" rates for treatments.

• Are doctor visits affected? No

• What about other health plans? No

• Exceptions: Patients in the middle of certain cancer treatments or who are in their third trimester of pregnancy will continue to get "in-network" rates, as will patients with symptomatic AIDS or end-stage renal conditions.

• More help? Call the number on the back of your United Healthcare, PacifiCare or Secure Horizons card; call your physician or HealthOne hospital where your treatment is scheduled; or call the state's insurance division at 303-894-7499.

scanlon@RockyMountainNews.com or 303-442-8729