Choice cuts

Milwaukee-area health care providers are tightening their health care insurance benefit plans to discourage employees from seeking medical attention at competing facilities. Many health care providers require their employees and their family members to pay more out of their own pockets to receive health care from physicians outside of the company’s health care network.
Milwaukee-based Aurora Health Care, which previously offered an HMO and a PPO for its employees, eliminated the HMO option at the beginning of this year. Some employees, whose doctors were covered in the HMO but not the PPO, say they will be forced to decide if they want to pay more out-of-pocket for medical expenses or find a new doctor covered in the PPO network.
The Aurora PPO includes some non-Aurora physicians, according to Aurora spokesman Ron Irwin.
"We are strictly offering the PPO to employees," he said. "It’s not limited strictly to Aurora medical group physicians. The PPO may not have as many physicians as what the HMO would have provided."
Some Aurora employees are unhappy they are being forced to make a choice between paying more to keep seeing their own doctor or saving some money by switching to a new doctor.
"I feel awful about it," said an Aurora technical services worker, who asked not to be named in this report. The woman has seen her gynecologist, a non-Aurora doctor, for 15 years. "With a female, there is a confidence with your gynecologist. I just have a lot of faith in him."
The Aurora employee said she has not decided if she will switch doctors.
"I have to see out-of-pocket what it is going to cost," she said. "I hate to do this. I’ve never met a doctor like this. They treat you like you’re the only patient. Even when the waiting room is full of women, you’re never rushed."
Some physicians who treat Aurora patients also are upset about the company’s health insurance change because they fear it will likely cost them several patients.
Babbitz, Burstein & Nash, S.C., a medical practice on Lake Drive in Milwaukee, has 86 patients who are Aurora employees or family members of Aurora employees who are affected by the health insurance change.
"In a small practice, that’s an awful lot," said Barb Kopf, office manager for Babbitz, Burstein & Nash. "A lot of (patients) have come here for years, some for 20 years. They’re very upset."
The practice has about 3,000 regular patients.
"(The Aurora patients) are still a major part of our practice," Kopf said. "We don’t know what we’re going to do. Will it be a major (impact)? Probably not. Will it hurt us? Absolutely.
"They (Aurora) can do what they want. They’re a business. I’m not saying it’s unethical. You can understand it, that’s money back in their pot," Kopf said.
The elimination of the HMO is not an unusual health benefits plan change for an employer, Irwin said. From time to time, employees may need to establish relationships with different physicians if their employer changes its health insurance benefits plan or if they change jobs.
"This isn’t really anything new," Irwin said.
However, some smaller health care providers fear the health benefits plans that large health care providers create for their employees are designed to make it harder for small private physician practices to compete.
"The small practices are being driven out by the big conglomerates," Kopf said. "There’s no question about it."
Aurora isn’t alone among local health care providers in restricting employee options by providing disincentives to go elsewhere.
"Our health plan only covers you
if you go to our physicians or a network we have contracted with," said Cheryl Hill, vice president of human resources at Columbia St. Mary’s Hospital
in Milwaukee.
The Columbia St. Mary’s network includes Froedtert Memorial Lutheran and Community Memorial hospitals, Columbia St. Mary’s and Advance Health Care Physicians Group.
Columbia St. Mary’s executives want to encourage their employees to see their own physicians, if possible, Hill said. If they cannot receive a particular health care service at Columbia St. Mary’s, employees can be covered at Froedtert or Community Memorial.
If employees want to go elsewhere to receive a health care service that Columbia St. Mary’s, Froedtert or Community Memorial can provide, the employees will not be covered at all by the company’s plan, except in an emergency.
"We do believe we provide high-quality care here, and we do it at a substantially lower price than our competitors," Hill said.
Covenant Healthcare uses a three-tiered system that is designed to encourage employees and their family members to be treated by Covenant doctors or independent physicians who have negotiated attractive rates with Covenant.
"They can use anybody they want to, but they pay a higher co-pay (to see a non-Covenant doctor)," said Anne Ballentine, regional vice president of Covenant Healthcare System. "It’s giving them a financial incentive to utilize Covenant services."
Froedtert employees also must pay higher co-payments for being treated by hospitals or clinics outside of their preferred provider network. The company pays a 90-percent co-pay for health care from providers within the network and pays a 50-percent co-pay for health care from providers outside the network.
The network includes Froedtert’s facilities, the Medical College of Wisconsin and Community Memorial Hospital, but also includes Columbia St. Mary’s.
Non-Froedtert facilities in the network have agreed to charge a discount for serving Froedtert employees and their family members, said Carolyn Bellin, chief public relations officer for Froedtert Hospital.
Until this year, ProHealth Care employees could receive care at the company’s hospitals, Waukesha Memorial Hospital and Oconomowoc Memorial Hospital, without paying a deductible or a co-payment. Those employees also could receive health care at Children’s Hospital and Froedtert Hospital with a $100 co-payment.
As of the beginning of the year, ProHealth Care employees must now pay a 5 percent deductible for health care at Waukesha Memorial or Oconomowoc Memorial and a five percent deductible, plus the $100 co-payment, for health care at Froedtert and Chidren’s Hospital.
The change was made this year to reduce costs and encourage employees to reduce their utilization of health care, said Pete Boney, director of human resources for ProHealth Care.
To receive health care from other providers, ProHealth Care employees under their company’s insurance plan must pay either 20 or 50 percent of the cost, depending upon which insurance plan they select.
"It’s not so much to keep people from using Aurora and others. It’s more to keep the dollars in house," he said. "Also, we’re one of the least-expensive leading health care providers in the area."
January 7, 2005, Small Business Times, Milwaukee, WI