New Hampshire's official state motto is “Live Free or Die,” and business groups trying to attract new companies to the Granite State praise its spirit of entrepreneurship.
But some hospitals in New Hampshire are feeling constrained this year by a market force outside their control: the state's health insurance exchange for individuals in 2014 only has Wellpoint's Anthem Blue Cross and Blue Shield—the state's dominant insurer—as a participating carrier.
For 2014, state regulators approved an Anthem exchange network that excludes 12 of New Hampshire's 26 acute-care hospitals. Anthem's narrow network leaves out hospitals in some of the state's largest cities, as well as rural areas. But the insurer has said its exclusionary strategy enabled it to slash this year's plan premiums by about 25%.
Even in the state capital, the only hospital in town, Concord Hospital, opted out of this year's exchange network for Anthem, because it felt the insurer's rates were inadequate.
Hospitals also insisted that Anthem's 2014 provider network was inadequate, leaving gaps and hurting patients' access to care. But neither state regulators nor state legislators took action. And, despite concerns, New Hampshire's exchange has proven to be popular with consumers. New Hampshire is among 22 states exceeding 2014 exchange enrollment projections, a recent study found.
For 2015, four new insurance carriers will join Anthem in selling plans on the exchange. Harvard Pilgrim Health Care and Assurant Health are in, as are two member-owned cooperatives: Maine Community Health Options and Minuteman Health Inc. Assurant only will offer individual plans on next year's exchange, but the rest will sell products to individuals and small groups.
Insurers' negotiations with some hospitals continue, but state regulators said some carriers' exchange networks for 2015 will include all of New Hampshire's hospitals.
According to spokesman John Clayton of the New Hampshire Hospital Association: There is competition among hospitals in the southern part of New Hampshire, but the state as a whole is “very rural, so north of Concord the hospitals get very scattered, and public transportation isn't good up there. It is mountainous terrain, so the notion of critical access hospitals really matters.” Half of the state's hospitals—13 in all—are critical-access facilities offering 24-7 emergency coverage, he said.
What has exclusion from Anthem's 2014 exchange network in New Hampshire meant to hospitals? Here's what a few told Healthcare Dive:
Monadnock Community Hospital in Peterborough, N.H.
Laura Gingras, the hospital's spokesperson, said Monadnock “knows firsthand” that its exclusion from Anthem's 2014 network for individual exchange plans was “very disruptive” to its patients who had to leave physicians with whom they had long-standing relationships in order to get exchange coverage.
“It's very troubling for us because we're not able to fulfill our mission if we can't care for folks in our community. We're in a rural area, so if our patients can't see our doctors, they may have to drive up to an hour to find a doctor [who is accepting new patients],” she said.
Monadnock is a 25-bed critical access hospital, Gingras said. “We have about 26 primary care physicians [in the community], and they are all affiliated with us. We serve 13 towns.”
As for 2015: "We're thrilled that there are going to be other products on the exchange," she said, adding that the hospital expects to be included in one or more new exchange products next year.
Gingras cited the community's continuing support for its hospital. "I feel very grateful that patients are very frustrated with the situation, but they understand it wasn't the hospital's fault. It wasn't lack of advocacy on our part," she said, adding that Monadnock anticipates their return into its system next year for care "closer to home."
Frisbie Memorial Hospital in Rochester, N.H.
Frisbie is the lowest-cost Medicare hospital in its area by 20% to 25%, according to federal data, and it consistently scores highly on quality-of-care and patient-safety performance measures, said John Marzinzik, Frisbie's senior vice president and chief financial officer. Yet becoming a part of Anthem's 2014 exchange network “wasn't even discussed with us,” he said.
But Marzinzik said most of Frisbie's anger over Anthem's narrow network is because it is "destroying doctor-patient relations," some of which date back 15 years or more. "We employ 99% of the primary care physicians in our community," Marzinzik said. That adds up to about 60 doctors in all, including PCPs and specialists, he went on. “So the patient builds trust in these doctors, and then [is] told that,'To get coverage through the exchange, you have to go to a different hospital,'" and also find a new doctor.
Unlike New Hampshire's isolated small, rural hospitals, Frisbie is in a competitive market. "Within 45 minutes of this hospital, there are probably six hospitals," Marzinzik said. Of the six, two hospitals were included this year in Anthem's exchange network, he said.
Frisbie sued the state insurance commissioner, requesting a public hearing on the adequacy of Anthem's provider network. It got a hearing in March, other hospitals voiced concerns, and the commissioner concluded that Anthem's network “came within reasonable boundaries of adequacy,” Marzinzik said.
Now Frisbie, a 112-bed hospital, is turning to 2015. Marzinzik said that he has reached an agreement with all four of the other carriers for their individual and small-group products being sold on and off the exhange next year.
Frisbie has no agreement with Anthem for next year's exchange plans, Marzinzik said. But Frisbie signed a new three-year contract with the company in October 2013, he said. "So we are a good Anthem provider. All of their patients, except for those on the exchange, can come to us," he said.
Marzinzik said Frisbie has a new ambulatory surgery center included in Anthem's 2015 exchange product, "so we have no animosity toward Anthem. They made a business decision. Our angst revolved around our patients being able to continue with their physicians."
Valley Regional Hospital in Claremont, N.H.
Peter Wright, Valley's president and CEO, asserted that Anthem excluded his 25-bed critical access hospital for its 2014 exchange network because it is located in Sullivan County, the second most socio-economically depressed county in New Hampshire. By contrast, he said, Anthem brought both hospitals in Machester, a relatively prosperous place, into this year's network. Anthem's aim was to "craft a network avoiding people in the high-risk pool and maximizing their profits," he said.
According to Wright, "65% of everything we do for this community falls under Medicaid, Medicaid or the financial assistance program." Valley's level of uncompensated care is 11.4%, nearly twice the statewide average of 6%. "If we were at the statewide average, that would be a difference of about $6 million," he said.
Wright described Claremont as “the kind of community the Affordable Care Act was designed for"—where the exchange would help get proactive healthcare to many people who otherwise couldn't afford it. If they opt for exchange coverage, they can't cross the state line to go to the closest hospital, which is 10 miles away in Vermont; but another five hospitals are in-state within 25 to 40 miles.
This year the bottom-line, Wright said, is that people in Valley's financial assistance program must choose between getting exchange coverage and keeping local providers. If someone insured by an exchange plan is hit by a car, he said, "we can give emergency care, but if they need orthopedic surgery, we have to ship them to another hospital."
As for 2015, Valley has negotiated exchange-network contracts with Harvard Pilgrim, Minuteman—and Anthem, Wright said. Anthem "was forced to speak with us as a result of the pending CMS rules change that requires narrow networks to include essential community providers," since Valley Regional is an ECP for Sullivan County, he said.