Thanks to Jack Sullivan over at CommonWealth Magazine, we now have an new chapter to add to the story of the referral of a patient by one hospital to its higher priced affiliate. In particular, we get to add the insensitivity of the insurance company to that of the provider network. We can now understand more fully the nature of the problem faced by this patient.
Remember the background. A patient was told that he could not get his prostate surgery done quickly enough at the lower-priced hospital, but could get it done at the higher-priced one, by the same surgeon. It was not until afterward that he realized that his two-tier insurance company would charge him more for the service. He was never told it was the same health care provider system.
I am not surprised by the comment from the provider network, even though it is totally off-point, as the care received by the patient would have been exactly the same at either hospital:
[A] spokesman for Partners Healthcare dismissed questions about a potential conflict of interest and said all care decisions are based on the health of the patient.
But here's the reaction from the largest insurer in the state:
[Patients] have to wrestle with the fact it’s going to cost more money if they choose a higher-tier hospital.... The copays are designed to incent a thought process around quality and cost. Members still get a choice but it costs them more out-of-pocket. It costs the health care system less.
If a patient is not told that the choice is going to cost more money, shouldn't the integrated provider network refund the difference in the co-pay? But, better yet, shouldn't someone have told the patient that there was a financial consequence in the decision being made? But, even better, shouldn't the provider system have figured out how to deliver the service at the lower priced hospital?
Here's another unanswered question: Do Faulkner and the Brigham receive the same technical fee for this surgery? I am guessing not, in that they are in different tiers. So, net of the higher copay, did Blue Cross still pay more for the surgery than it would have had it been at the Faulkner? If so, does it care about that?