At the Council on Aging of Buncombe County, Susan Wilson oversees a program across 11 counties in Western North Carolina that helps patients 60 and older navigate the complexities of the Affordable Care Act.
With a few exceptions for those whose circumstances change during the year, people can only sign up for coverage under the ACA during the open enrollment period, which ended on Dec. 15 for 2018.
Wilson says she’s worked five open enrollment periods so far, but the most recent was the toughest. One of the big reasons? The anxiety caused by the contract dispute between Blue Cross Blue Shield and Mission Health.
“For the most part it seemed that people had enough frustration, exasperation and anger to cover both Blue Cross Blue Shield of North Carolina and Mission,” Wilson said. “It seemed that we had two 800-pound gorillas pounding on each other, putting patients at risk.”
For about two months, Mission Health was out of Blue Cross Blue Shield’s network following a prolonged and public dispute about reimbursement rates.
Blue Cross is the only health insurance provider in Western North Carolina that offers insurance through the Affordable Care Act. This year, that monopoly limited the available care options for many of Wilson’s clients living in the area.
She, along with many other members of the community, breathed a sigh of relief when she read in early December that the two companies had agreed on a new contract, which went into effect on Dec. 15.
“People were calmer and happier with their choices all around,” she said.
A new start
On July 5, Mission Health announced its intent to terminate its contract with Blue Cross Blue Shield of North Carolina at midnight on Oct. 4 if the insurer didn’t agree to provide the health system with higher reimbursement rates for its services — an increase that Mission said was necessary to keep up with rising health care costs.
In early September, Rowena Buffett Timms, senior vice president of government and community relations at Mission, told Xpress about 70 percent of Mission’s patients are covered by Medicare or Medicaid or are uninsured, while a quarter of the health system’s patients are covered by commercial insurance. Of those patients with commercial insurance, about 70 percent receive their insurance from Blue Cross.
Neither Blue Cross nor Mission have agreed to share information about their new contract, but they did release a short joint statement.
“Both parties are pleased to reach agreement on the mutual goal of ensuring that the people of Western North Carolina receive the affordable, quality health care that they need,” it says in part.
In her role as an insurance navigator, Wilson says she has heard from many people who asked for help finding a doctor not in the Mission Health system who would be in the Blue Cross network.
“Many people were angry with BCBS because they were happy with their Mission doctors and services and were upset that they felt forced to choose between comprehensive insurance or their chosen medical care providers,” Wilson said.
Wilson and her staff referred people to Park Ridge Health and Pardee Hospital, where Blue Cross patients could expect to be in network.
In an open letter circulated in late September, Pardee Hospital stated it was gearing up for an uptick in Blue Cross Blue Shield patients visiting the facility’s urgent care centers and physician practices in anticipation of the termination of Blue Cross’s contract with Mission.
“That uptick did occur,” said James Kirby, president and CEO of Pardee UNC Health Care, in a statement to Xpress. “Many expressed appreciation that Pardee had the facilities and the capacity to provide care to them during this time of transition and uncertainty.”
Victoria Dunkle, communications director for Park Ridge Health, says her system saw a similar increase in patients starting in July 2017, “primarily from people with Blue Cross Blue Shield plans but also from people with insurance through other carriers as well.”
Dunkle says the number of calls and scheduling that Park Ridge received increased as the October deadline crept closer and have remained steady. She says the system also received requests from several surgeons to use their operating rooms.
Complications with affordable care
The Affordable Care Act weathered some punches in 2017. Republicans tried unsuccessfully to repeal the law, and President Donald Trump signed several executive orders designed to hamstring some of its fundamental pieces.
The enrollment period in 2017 was also much shorter than in previous years — six weeks instead of 12 weeks — but even that didn’t seem to have a significant impact on enrollment numbers in North Carolina.
Jaclyn Kiger, managing attorney at Pisgah Legal Services, says in the six weeks, 523,989 people in North Carolina signed up for health insurance, which is 95 percent of the enrollments from the 12-week open enrollment period in 2016.
In many ways, Wilson says the confusion caused by movement at the federal level was easier to deal with than the debacle between Mission and Blue Cross. “Mission and Mission-based practices are about the only choice many people have, and the increased cost of using anything Mission-related worried many people, especially those with chronic illnesses who were longtime patients in the Mission system,” she says. “We spent a lot of time helping people to find non-Mission practices and services when possible and working on continuity-of-care applications when appropriate.”
Continuity of care allows patients at out-of-network hospitals to continue receiving in-network care at that medical facility if they meet one of several qualifications.
Could this happen again?
In addition to their joint statement, Mission also referred Xpress to a Frequently Asked Questions page on its website.
One question cuts right to the chase: “Will this situation happen again?”
“We certainly hope not,” Mission states. “However, contract negotiations are a regular occurrence between providers and insurance companies. Our relationship with Blue Cross NC is very important, and we hope to avoid any disruption to patient care and coverage in the future. That said, we must ensure that our contracts continue to allow us to provide our patients the best quality care for years to come.”
Barry Smith, assistant director of public affairs with the N.C. Department of Insurance, agrees with Mission’s assessment, saying contract disputes like the one between Blue Cross and Mission do happen fairly regularly. “Fortunately, most are resolved by the parties prior to existing contracts actually terminating,” he says.
The Department of Insurance is in charge of regulating insurance companies in the state and closely monitored the dispute between Mission and Blue Cross beginning in late June when Blue Cross alerted the state of the possibility that Mission would terminate the contract.
The agency, however, doesn’t intervene in contract negotiations between providers and insurance companies. “Our leadership analyzed the issue and determined that the insurance company [Blue Cross] was technically compliant with requirements for having sufficient contracted providers for customers,” Smith says. “We recognized that the potential termination of the contract could have a significant impact on the insured customers that relied on Mission for certain medical services.”
Smith says the department of insurance is concerned about the possibility of the contract falling through again in the near future. “As the cost of health care service continues to rise, it is anticipated that the payers of the health care cost will continue to try to limit such increases in health care service costs, thereby setting the stage for either party to cause a termination of the contract between the insurer and health care provider,” he says.