Is Your Hospital on Your Health Plan?

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Matilda sat in the hall near X-ray holding up a wrinkled little hand. Tiny and looking every one of her 88 years, the woman, despite her broken English, was still with it. She had taken three buses and walked six blocks to get to my office — all by herself.

I bent over to take a look at her hand, which Mattie described as "locking and hurting and sleeping all the time." She had simultaneous and rather bad cases of two hand-surgery classics — carpal tunnel syndrome and trigger finger, a tendon-related condition that causes fingers to catch in a bent position. Other docs had given Mattie splints and shots, but her hand was getting worse. It was clear that if I didn't treat the carpal tunnel and release the pressure on the nerve in her wrist, and do it soon, she would never get better — the nerve damage would become permanent. Mattie's other problem, triggering, was bad too. It made opening her hand painful and difficult. My patient needed two small operations — just 15 minutes of actual surgery — to cure these problems.

Explaining the situation to Mattie was easier than I expected. She was a little deaf, but still a sharp cookie. She got the picture. "So, when do you fix it?" she wanted to know. I told her to make an appointment with my secretary and gave her the name of the nearest hospital, where I'm on staff.

"Oh, doct, I can't go there," she said immediately. "It's too much money." She opened her purse, produced a letter from Blue Cross and pushed it across my desk. It was the kind of long, maundering insurance-company letter that instantly makes my eyes glaze over. I told Mattie not to worry. She had insurance, so probably she'd only have a co-pay — usually about $50.

With age-dimmed eyes she scanned the page, jumped up, and pointing with her crooked, numb finger she put the letter in front of my face. "Right here — they don't pay if I go to that hospital," she said. "Why can't you do it in your office, doct?"

I looked at the letter, and she was right. I've worked at that community hospital for 20 years, and they finally did what so many of us in medicine have been thinking about doing for so long — they said, "No." They responded to yet another insurance-company rate decrease by refusing to accept it altogether. Hospitals can't afford to pay their nurses, buy medicines or give personal attention to each patient, if they're expected to treat so many, so fast, just to break even. Good for them, I thought. But, then, I looked at Mattie, and I looked at my day list of patients — fully half of them had the same kind of insurance she did.

So, what was I supposed to do with this patient? How could I get her to go to my other hospital, so much farther away? And how am I supposed to take care of all the others? There is no answer yet — we're waiting on negotiations between the insurer and the hospital. I twisted some arms for Mattie, and got the insurance company to pay the old rate for her treatment; I'll hopefully get her in soon, but this won't work for every case after hers.

When you choose a health plan, you typically check the panel of doctors it pays for. Now you need to check which hospitals and diagnostic facilities it covers too. And keep in mind, the list can change at any time. The unfairness of this bait-and-switch game — to both patients and doctors — is pretty nasty. The hospitals and facilities you signed up for originally might suddenly be replaced by facilities that are — you guessed it — cheaper. While your premium (and the CEO's bonus) goes up, the dollar value of what you're getting — i.e., what the company will pay your hospital or doctor for their services — goes down.

Mattie, a peppery little old lady, whose hand I have not yet fixed, alerted me to the present danger of a problem that we've watched fester for years, but never thought would actually happen. While letting insurance companies "bargain" for them, some patients have been priced right out of the market. You should check into this right now. Is your local hospital on your health plan?

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.