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News Primer: Frisbie Hospital Challenges Anthem's Provider Network

Sara Plourde

 In the pitched political battle over the Affordable Care Act, Republicans and Democrats seem to have found common ground on one issue: Anthem’s so-called narrow network of providers.

From GOP Senate candidate Scott Brown to Rep. Carol Shea-Porter, a wide array of voices have complained that Anthem’s decision to exclude 10 hospitals from its plans sold through the new federal health exchange harms patients.

On Wednesday, one of those patients, an East Rochester woman named Margaret McCarthy, will get a long-awaited hearing on the matter at the state Insurance Department.

Here’s what you need to know about the hearing and how it could affect the Affordable Care Act in New Hampshire.

Who is Margaret McCarthy?

McCarthy, who is in her early 60s, buys her health insurance through Anthem. Her primary care doctor is affiliated with Frisbie Memorial Hospital, whose president, Al Felgar, has led the opposition to Anthem’s provider network.

McCarthy and Frisbie filed a complaint with the Insurance Department last fall, alleging they’d both been harmed by Frisbie’s exclusion from Anthem’s network and that the Department shouldn’t have given regulatory approval to the insurer’s plans.

What is the basis for McCarthy’s complaint?

McCarthy claims she’s been harmed because in order to be eligible for subsidies under the Affordable Care Act, which would lower her premium costs, she would have to purchase a plan through the federal health exchange.

But because Frisbie is not part of Anthem’s network, she’d have to change doctors if she wanted a subsidized plan.

McCarthy opted to renew her old Anthem plan late last year, which means that, for now, she can still go to Frisbie and see her doctors. But she’s paying more than she would if she had signed up for a new plan under the Affordable Care Act.

What is Frisbie’s issue with Anthem’s network?

The hospital says Anthem’s decision to exclude it, but allow in Wentworth Douglas Hospital — just eight miles down the road in Dover — “materially impairs Frisbie’s ability to compete.”

Felgar has argued that the narrow network harms Frisbie economically because the hospital can’t even try to serve patients who buy coverage through the Affordable Care Act.

State Insurance Commissioner Roger A. Sevigny threw that complaint out, though, ruling that his agency doesn’t control which providers an insurance company decides to contract with.

What is Anthem's response?

Anthem has argued all along that the only way to keep its new plans affordable is to reduce the number of hospitals and doctors. The insurer says policies would be 25 percent higher if it included every hospital in the state.

An insurance company is really a negotiator - they sit down with a hospital or a doctor and say, ‘If you contract with us and become part of our network, we’ll pay you for the services you provide.”

What Anthem has basically done is reduce what it will pay for services while limiting the number of doctors and hospitals that provide those services.

The patient benefits because costs are lower. The hospital or doctor benefit because, with fewer providers in the network, more patients are walking through their doors.

This is not unique to the Granite State - narrow networks are popping up all around the country right now. And most people with insurance are accustomed to being limited to specific doctors, although not usually to only certain hospitals.

Has this affected how the Affordable Care Act has worked in New Hampshire?

The intent of the Affordable Care Act was to improve access to health care - to get more people into the doctor’s office, so you get fewer people ending up in the emergency room. Or if people do end up in the ER, they aren’t forced into bankruptcy by unanticipated medical costs.

But by having only one insurance company selling plans in New Hampshire this year, opponents of the law say it's actually reduced access to health care.

On the other hand, supporters of health care reform, while not exactly quick to defend Anthem, say more people are getting covered, and at the end of the day, that is what matters most.

What could happen as a result of Wednesday’s hearing?

It’s unclear.

The Insurance Department can’t force an insurance company to contract with a provider, so it’s unlikely Anthem will be forced to add Frisbie to its network - even if the commissioner agrees Margaret McCarthy was harmed.

And the whole issue will probably resolve itself next year when more insurance companies will be joining the marketplace, giving consumers more choices and, more than likely, at least one full network of hospitals.

There will also be more transparency in how these plans get regulatory approval in the future. Both the House and Senate have passed a bill that requires the Insurance Department to hold public hearings before approving new policies.

And one of the things that will have to be disclosed in those hearings is the network of hospitals available under each plan.

Todd started as a news correspondent with NHPR in 2009. He spent nearly a decade in the non-profit world, working with international development agencies and anti-poverty groups. He holds a master’s degree in public administration from Columbia University.

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