A Boston Globe story raises a number of questions, but not the ones suggested by the title, "Tiered health plans cutting costs, restricting options." You read the lede and see if you catch my drift:
Told he had an aggressive form of prostate cancer, Glenn McCarthy faced a decision this year. He could make a $1,000 copayment and have surgery at Brigham and Women’s Hospital in about two weeks. Or he could wait more than a month for an opening at Faulkner Hospital, paying just $150 for the same procedure by the same surgeon. His doctor advised against a delay. “It was life or death,’’ said McCarthy’s wife, Tracy. “We really didn’t have a choice.’’
The issue here is that Faulkner Hospital is owned by the Brigham. See this logo from its website:
Indeed, we even find stories on that site about prostate surgery.
Many questions arise from the Globe story, since we know that the technical capacity (i.e., equipment, supplies, support services) to do the surgery exists in both hospitals:
Why couldn't the surgeon do the surgery in timely fashion at the lower-cost affiliated hospital? Was this his choice? Did he know a failure to do so would cost his patient extra money? Was his choice limited by the OR times made available to him by the hospital administration? Did the surgeon ask the administration to make room on the schedule to avoid the extra cost to the patient? Is there anyone at either hospital who acts as an ombudsman or facilitator to help patients receive their care in the lower cost hospital? Is there pressure on surgeons to fill up the operating schedule at the Brigham to help offset the operating costs of the more expensive institution?
In short, this case does not seem to be about the features of tiered health plans so much as the features of an integrated provider network that either acted inadvertently or affirmatively to cause a patient to spend more money than necessary for an important procedure. If the former, it is a shame. If it is the latter, it is an outrage. Or maybe there is a more innocent explanation. Who will ask the questions?