To Blue Cross & Blue Shield of Rhode Island President Ronald A. Battista, the issue is clear: Choice in health care costs money, and if you want it you must pay for it. But David S. Elliot, president of the Rhode Island Psychological Association, takes an opposing view. It’s possible to save money without limiting choice, he said.
The two men represent different sides of a debate going on across the nation: How can high-quality health care be made affordable and accessible?
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With its much-publicized “Project BluePrint,” Blue Cross hopes to discover what Rhode Islanders think. It is collecting surveys, conducting public health care forums, and will soon interview residents over the phone.
One of the company’s aims is to gauge public support for limited – or specialized, the term Battista prefers – networks of health care providers. These networks will keep costs down, Battista said, as they do all across the country. Rhode Island has just been slow to catch on, he said.
Here is how networks work: A health insurer forms agreements with select health care providers, agreeing to channel patients to those in the network. In return, members accept lower reimbursements.
Blue Cross already uses these networks to a limited extent. Under the company’s BlueCHiP plan, its health maintenance organization product, patients go to a specialized network of labs, durable medical equipment providers, and vision care services.
But while these networks are indeed saving the company money, Battista refers to them as “dancing around the edges.” What he would really like is to create networks of doctors and hospitals. He would create a set of standards by which Blue Cross would like to do business with them, and find out which can meet those criteria. Therefore, hospitals and physicians would go through a process not unlike the Request for Proposals exercise that municipalities use to award contracts, Battista said.
”All of these networks are paying dividends,” he said. “They’re willing to give us discounts that otherwise we would not get.”
BlueCHiP is now 6 to 8 percent cheaper, on average, for businesses than the company’s next most expensive product, HealthMate 2000, Blue Cross’s Preferred Provider Organization.
But by increasing the use of limited networks, the price difference could increase to 15 percent, Battista said. And that is exactly what he wants. The bigger the price difference between BlueCHiP and HealthMate, the better, he said. The problem now, he said, is that BlueCHiP and HealthMate are highly similar in the way they operate, with each requiring patients to select a primary care physician who then directs patients to specialists.
By making BlueCHiP significantly cheaper, the two products will be easier to differentiate, he said.
Battista added, however, that he has no plans to scrap either HealthMate or Classic Blue, the traditional indemnity plan that offers patients complete freedom of choice about whom they go to see. Blue Cross, he said, simply wants to give patients the choice of plans.
The critics of this plan, he said, “want to take the choice from the public, saying, ‘Specialized networks are not for you,'” Battista said. “It isn’t a silver bullet, but certainly it has a place in the spectrum.
“We should have the right to sell it, and you should have the right to buy it,” he said.
To earn that right, Blue Cross would need approval from the state Department of Business Regulation. It may also need to fend off state legislators who might want to foil its plans. By conducting the survey, Blue Cross hopes to be able to build a case based on public support for networks.
But, “We’ll live with whatever answers there are,” Battista said.
But the questions lead people to the answers that Blue Cross wants, argues Elliot and critics.
For example, one question asks respondents to rate the importance of a plan that would “let me go to any doctor I want even if I have to pay extra for the visit.” According to Elliot, that question should be broken in two. One would ask the importance of being able to go to any doctor. The second question would ask respondents to rate the importance of choice, even if it costs more, he said.
The implication of the current survey is that choice necessarily costs money, Elliot said. This is not true, because health insurers can cut costs in other ways, such as by trimming administrative expenses, he said.
”The survey has very little scientific merit,” Elliot said. “Blue Cross seems to be saying through this survey that they believe that it’s important to limit the networks in order to save money, and I don’t think there’s documented evidence (to support that).”
In a briefing paper Blue Cross published in September of last year, the company said “networks will play a large part in the company’s future success. The inability to form networks would have a profoundly negative impact – not just on Blue Cross, but on the Rhode Island health care system.”
Those negative effects would come in the form of increased premiums and curtailed products. Portions of the population will no longer be able to afford health care without networks, the paper said.
Critics of networks, Battista said, are providers who are afraid of losing volume of business. And with the savings that networks provide, elements of the population that are having trouble paying their health care bill would be better able to do so, he said.
But there is another side to networks, argues Elliot. Many experienced doctors and mental health care providers would choose not to accept less money in exchange for more referrals, especially those who have enough business already.
Therefore, the people who make up the networks tend to be those with lesser experience, he said.
”The most skilled and most experienced providers don’t want to play that game – there are many clinicians who have no incentive to participate in a system that will bring them more business than they already have, ” Elliot said. “And so the public has fewer highly skilled providers to choose from.”
Elliot added that he does not take a purely antagonistic view of Blue Cross’s motives.
”Legitimately, they have concerns about expenses and health care costs,” he said. “I applaud them in principle. I applaud them for wanting to hear from the community, but the written survey doesn’t inspire confidence that they will approach, in an objective way, what the community wants.”
