Fighting Surprise Out-of-Network Doctor Bills
The 32BJ Health Fund is taking on surprise bills from out-of-network (OON) providers. Health Fund Director Sara Rothstein testified at a December 12th New York City Council hearing about the problem of surprise bills from OON providers and called on the City Council to require hospitals with physical locations in New York City to disclose the insurance networks accepted by each hospital, the total number of doctors with credentials at each hospital and the total number of doctors who are in each insurance and/or benefit network accepted by each hospital. The issue and Rothstein’s comments got extensive coverage in Bloomberg and other outlets.
When plan participants receive a surprise bill from an OON provider for services performed at an in-network hospital, the Health Fund ensures that participants don’t pay more for needed care than they would have paid if services were performed by an in-network provider. When surprise bills cost significantly more than what an in-network provider would have been paid for the same care, the Health Fund must pay more to the OON provider than it would have paid to an in-network provider. These expensive bills jeopardize the Health Fund’s ability to keep costs low for participants and for contributing employers.
Prevalence of OON Providers by Health System
The Health Fund analyzed claims from OON providers who provided care to a Health Fund plan participant in an inpatient or outpatient hospital setting. This analysis identified the following:
- The Health Fund paid $4,237,680 to OON providers who provided care at a Northwell hospital. This is more than the total amount that the Health Fund paid to OON providers at any other health system in downstate New York.
- Number of Claims from OON Providers – The Health Fund had 5,751 claims from OON providers at Northwell hospitals, which were more OON provider claims than at any other health system in downstate New York.
- Number of OON Providers – The Health Fund paid 947 OON providers at Northwell hospitals, which was more OON providers than at any other health system in downstate New York.
- The Health Fund analyzed claims from OON providers providing care at Northwell hospitals to determine if the OON claims were concentrated in certain specialties. The Health Fund found that 39% of the claims and 42% of dollars spent were from Internal Medicine and Cardiology providers combined at Northwell hospitals.
Surprise bills aren’t only a matter of concern to the Health Fund. Patients and other payers alike should be concerned about the prevalence of OON providers providing care to patients at Northwell hospitals. When a health system is innetwork, patients expect that the providers who provide care there are also innetwork. This is especially true when patients are already admitted to an innetwork hospital and don’t have a choice of provider.
The Health Fund started an education campaign to inform participants that they could receive surprise bills from providers at Northwell hospitals and urged participants to contact the Health Fund if they need help finding innetwork doctors who will not issue surprise bills.
Communicating Plan Changes Clearly to Preserve Trust
The 32BJ Health Fund introduced a new and innovative network design in April 2019. For the first time in its history, it differentiated between health systems in the New York City metro area. While most health systems would be preferred and keep the same low copays, others that charged significantly more for care would become non-preferred and have significantly higher copays for planned care. While most plan participants were already using preferred hospitals, the goal of the new design is to increase the number of participants using preferred hospitals when they need hospital-based care.
Before implementing the changes, the Health Fund developed a communications plan to inform participants of the changes, help participants find preferred hospitals for care, ensure they knew how to get help if they needed it, ensure they knew why the change was happening and maintain the favorable view most participants had of their health plans and their trust in the Health Fund.
The goal was to communicate early and often with participants through a variety of formats and languages, including 2-3 pieces of mail per month to participants in the three months leading up to the change; additional mailers to people who previously used non-preferred hospitals and those it knew were in its maternity program and would give birth in the coming months; a robust field plan for Health Fund staff and union staff to bring information to union members’ worksites and regular union meetings; updates to highlight the change on the website; and a series of emails in the weeks leading up to the change.
The mail program included a mix of federally-mandated mailers to describe plan changes and a series of accessible and compelling pieces that were easy to read and clearly outlined the changes in simple language. The centerpiece of the campaign was a glossy eight-page brochure that presented the most compelling arguments and offered a pull-out card with specific questions that participants could take to their doctor if they had inpatient or outpatient care planned and wanted to make sure they’d be treated at a preferred hospital with the low copay.
All materials were produced in English and Spanish, the two languages spoken by the majority of participants. Communicating in their preferred language was key to making sure that there were no language barriers to understanding the information.
After the changes in the plan became effective on April 1st, the Health Fund has continued to communicate with participants via email and mail, including two recent mailers reminding all participants of the changes. The Health Fund also sends a letter to all participants who use a non-preferred hospital for planned care to explain why they paid a high copay and what their options are for receiving care at a lower cost to them.
For more information, read our full case study here.
Maternity Program Aims to Transform Care for Expectant Mothers
In August, the 32BJ Health Fund launched its ambitious 32BJ Maternity Program to improve the quality and safety of maternity care for plan participants; to educate working people in New York and New Jersey about their options for respectful and high-quality labor and delivery care; and to transform the way health plans and hospitals prioritize services for mothers, especially women of color.
The new program from the Health Fund aims to lower the rate of maternal harm in its population by identifying high performing hospitals and educating participants so that they choose Better Births providers for their maternity care.
Childbirth is the number one reason for planned hospitalization for participants of the Health Fund. Of the approximately 1,300 births covered each year by the Health Fund, most of them are in New York and New Jersey. In 2018, the Health Fund spent almost $23 million on costs related to those births. When the Health Fund examined its own claims data related to labor and delivery, it saw an excessive rate of maternal harm, including a high incidence of C-sections and an excessive rate of episiotomies.
The Health Fund asked hospitals to share key information about their rates of maternal harm and about whether they follow nationally recognized best practices to keep moms and babies safe and healthy. The Health Fund will use that information to educate participants about their options for delivering their baby.
According to the Centers for Disease Control and Prevention (CDC), more than 50,000 American women are harmed giving birth each year. Although many developed countries have enacted changes to effectively reduce maternal mortality, maternal death rates in the United States continue to increase. The lack of adherence to safety measures, excessive use of C-sections and inappropriate early elective deliveries lead to harmful complications for both mothers and babies.
“The goal is to provide respectful and safe care for 32BJ Health Fund participants when they have a baby,” said Health Fund Director Sara Rothstein. “Many of our participants are women of color. Statistically, black and Latinx women are at increased risk of harm. The Health Fund is committed to fighting the racial disparities in maternal care and to ensuring that women can give birth safely.”
The project began with a Request for Information (RFI) to hospitals in Northern New Jersey, New York City, Long Island and Westchester, inviting them to apply to the program and provide information about their facilities.
The Health Fund is evaluating responses and developing a high-value maternity network. It will then launch a participant education program to help 32BJ members decide where to give birth. By partnering with high-value providers, the Health Fund aims to reduce dangerous complications like hemorrhage, sepsis and unnecessary C-sections. It also hopes that hospitals will use this opportunity to increase access to providers who can improve outcomes, such as midwives, doulas and lactation consultants.