CEDAR CITY – Rep. Chris Stewart took a detour earlier this month during his visit to Southern Utah to meet with orthopedic surgeon Randy Delcore in Cedar City to listen to concerns the doctor has with Intermountain Healthcare and insurance provider SelectHealth.
Delcore invited Stewart to stop by his medical center to discuss several issues and asked the Congressman for help in what he believes is an attempt by IHC to push him and others like him out of business.
Medical providers, doctors for example, contract with insurance companies and in doing so agree to certain conditions imposed on them by those insurance companies. This enables the medical providers to accept a company’s insurance for their patients but, by extension, requires them to impose the insurance company’s conditions on their patients which can, in some cases, increase the ultimate costs to the patient.
For example, Delcore said, several insurance companies are requiring him to provide his services to patients at the hospital that he might otherwise be able to provide in his own surgical and imaging facilities, Cedar Orthopedic Speciality Center and Southern Utah MRI.
Delcore said SelectHealth is refusing to contract with him to insure patients for MRIs performed in his own imaging facility and surgeries performed inside his outpatient surgical center.
SelectHealth has several different insurance networks, three of them private and three underwriters for the government. These include Select Choice, Select Care and Select Med which are all private insurance and SelectHealth Advantage, SelectHealth Community Care and SelectHealth Share.
Delcore and his imaging center are contracted with the private health care networks. However, none of the SelectHealth networks cover his surgical center but have limited their surgical coverage to patients treated at the hospital.
“Across the board,” Delcore said, “with all metrics, surgery centers have shown lower infection rates, much higher patient satisfaction scores probably because (of their) less clinical more personal environments and more hands-on.”
Delcore is not contracted at this time with any of the government networks but has been invited to join, said Jon Pike, regional operations director for Southwest SelectHealth.
“We have invited him to join and are in the process of negotiating those terms,” Pike said, “because Dr. Delcore has said he would join if we contract with his MRI facility; so we are now discussing that.”
Delcore said the contracts he does have with SelectHealth, one of the largest insurance providers in Southern Utah, will be tightening after the first of the year.
“Up until now if you weren’t a provider for SelectHealth they still have out-of-contract benefits but starting Jan. 1 (2016) there’s no out-of-contract benefits,” Delcore said. “They’ve taken the year to gather the flock in and now they’re locking the gate and you have no other options. So it takes away the choice.”
What this means for the patient, he said, is more expensive health care because all surgical care is restricted to a hospital setting.
Pike agreed an outpatient surgical center such as Delcore’s may offer some out-of-pocket savings to the patient because of the hospital’s overhead and administrative costs but said the savings for the insurance companies comes in volume which savings are then transferred to the patient.
“They (insurance companies) are looking at what kind of volume are you going to deliver to me,” he said.
Daron Pealock, registered nurse with a Bachelor of Nursing and administrator for Cedar Orthopedic Surgery Specialty Center, said he tried to get the insurance provider to contract with Delcore for months. Finally, he said, he was told by a SelectHealth representative the company’s contract with IHC prohibited it from signing a contract with the doctor.
Under the law, any contract between providers and insurance companies are confidential so the SelectHealth representative could not give him the details of the contract with IHC, Pealock said.
“They won’t give me a reason why because they can’t,” Pealock said. “The law says insurance contracts are considered proprietary so what that means is, it’s confidential and they can’t talk about the details of their terms. All they’ll tell me is that their contract with IHC prevents them from contracting with us.”
Delcore said he has also asked for a letter from SelectHealth representatives stating the reason the insurance company won’t contract with him and each time he has been denied.
“Every time they tell me, ‘you know we can’t do that,’” Delcore said. “I just want something I can move forward with but they won’t. They’re brilliant. They’re brilliant strategists to just say no and don’t cause too much of a ruff or we’ll do what we’re doing to you now.”
The issues have also rippled out to other insurance companies, Pealock said, including Educators Mutual Insurance and Coventry, that have both recently denied Delcore a contract citing their ongoing contract with IHC as the reason.
United Health Insurance is another company refusing to contract with Delcore but has not stated a reason for its refusal, he said.
Pike, who stressed he only represents SelectHealth, said IHC will often offer savings to insurance companies in return for an exclusive contract. However, he added, no one forces the insurance companies to restrict health care coverage to one provider.
“What I do know is, no one makes these insurance companies like EMI, Coventry, and United sign a contract with only IHC,” he said. “They choose that because they believe it offers them the best discount and savings that ultimately transfers to savings for the consumer.”
These types of negotiations aren’t unique to IHC, Pike added, but are done all the time in an effort to bring savings to the insurance company and to the consumer.
Delcore called the whole thing “un-American,” and said the way it is going it is creating a monopoly in the health care industry.
“It’s Economics 101. If only one person is providing a service and only one entity is providing a service, the prices are fixed. You have no way of finding anything cheaper,” he said. “It’s anti-competitive. It’s antitrust.”
In his conversation with the congressman, Delcore blamed the Affordable Care Act for some of the problems, but he also believes, he said, it’s an issue with the current “any willing provider” law in Utah that says insurance companies should contract with any provider willing to do so.
While the law was written in an effort to protect doctors by allowing them the opportunity to contract with major insurance providers it falls short in doing so, Delcore told Stewart.
“Let’s empower our ‘any willing provider’ law. The law has been on the books since I can remember. We enjoy that law that’s there but it never gets exercised or empowered and nobody will fight it because they’re fighting a giant,” Delcore said referring to IHC. “It has no legs. No one will stand behind it.”
Pealock said the law has no teeth because it fails to demand that insurance companies contract with providers who are willing to do so.
“The law says insurance companies ‘should’ contract with any willing provider but that’s it. It doesn’t say they have to or that there’s a penalty for not contracting with them it just says they should,” he said.
Pike also said the law only covers rural areas and does not include Washington and Iron counties.
Since the law stems from state jurisdiction, Stewart said, he encourages Delcore and his staff to contact their state legislators to work on making changes to the law.
“Go to the state because that’s where you’re going to find your relief. Happy to talk to you any time and there are federal issues that we can talk about, that we should talk about,” Stewart said. “On this one particular thing your immediate relief is going to come from the state.”
Stewart told Delcore there is nothing he could do on the federal level with the current administration in power but asked him to contact his staff anyway to let them know what problems he is facing since the passing of the ACA.
“We’re kinda kicking our heads against the bricks under this administration (Obama) if we think we’re going to make any changes,” Stewart said. “But get with my legislative director, Gordon Larsen, to see what together you guys can come up with as far as if you think there’s something we can do back in D.C.”
Copyright St. George News, SaintGeorgeUtah.com LLC, 2015, all rights reserved.
Copyright St. George News, SaintGeorgeUtah.com LLC, 2015, all rights reserved.