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Patients’ anger as treatment choices denied

As Bermuda’s health spending climbs ever higher, insurance tactics to contain costs result in some patients being effectively denied the overseas treatment of their choice.

Allan DeSilva, of the Bermuda Healthcare Advocacy Group (BHAG), needs back surgery that he cannot obtain in Bermuda — but found his operation would only be covered by his local insurer to the tune of ten per cent.

“I’ve never been away in my life for medical services — I want to go to the surgeon of my choice,” Mr DeSilva said. “It’s my life, my back, and for the amount of money I’m paying, I see no reason to be shut out.”

For the “delicate” surgery on his thoracic and lumbar vertebrae, Mr DeSilva’s doctor recommended he obtain treatment from a physician at Connecticut’s Griffin Hospital, which has had a high rate of success with the operation.

However, his insurer told him “he isn’t on their network”, Mr DeSilva said, while treatment at New England Baptist Hospital gets full coverage.

“I have nothing against them but I don’t know their doctors. I do know the success rate of Griffin Hospital, and there are more than 100 people from Bermuda who have been there.”

Worse, he said, was that other Bermudian insurers do network with Griffin.

“I can’t change my insurance because I have it through my job,” Mr DeSilva said. “I pay out $1,550 a month. That’s more than $18,000 a year. It’s exorbitant.

“My doctor at Griffin is even willing to charge me the same as what the preferred place would charge. But it’s been six months now and I don’t have any answer.”

For one woman, who asked not to be named to protect her privacy, the lack of choice is especially grave.

Stricken with an extremely rare cancerous tumour attached to her sciatic nerve, she needs treatment abroad. The tumour is known technically as a schwannoma.

“When I found out, I went online and found that the best surgeon is at Johns Hopkins — that’s where the leading specialist is,” she said.

“It’s extremely rare. It’s so rare they can barely find any information on it. But my insurance company said I would have to pay 50 per cent. I’d have to go to Lahey Clinic to be covered, even though Lahey told me I would need two surgeons, not one.

“What concerns me is that if they screw up the surgery on my sciatic nerve, I will have what’s called a dropped foot. I’ll lose mobility in my foot. It will affect me for the rest of my life.

“I have fought this tooth and nail, it’s been a real ordeal. My insurance company insists they will take care of me at Lahey.

“I’ll go and listen to the doctors but if I’m not comfortable, I will come back home. I’ll get treated at Johns Hopkins even if I have to pay for it the rest of my life.”

After speaking with patients, The Royal Gazette asked Argus, BF&M and Colonial insurance companies to explain their policies on overseas care.

The use of overseas networks emerged as a necessary tactic for containing costs.

According to the Bermuda Health Council, more than $100 million leaves the Island each year for treatment abroad.

Michelle Jackson, executive vice president of group insurance for the Argus Group, said the insurer’s network encompassed more than 10,000 acute care facilities and 600,000 doctors in approximately 130 countries — including “some of the world’s best facilities, such as Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Johns Hopkins Hospital and Lahey Hospital and Medical Center”.

“We work with physicians and hospitals to provide 100 per cent coverage at some of the world’s best facilities, while still controlling premium costs,” she said.

“In 2010, Argus developed an overseas Preferred Provider Network where we partner with facilities selected from the worldwide Argus Network. The Preferred Provider Network includes more than 40 facilities in the US and Canada where we have negotiated preferential rates.”

Ms Jackson said the insurer also reined in overseas costs by being diligent in its review of claims abroad.

“Over the past two years at the Argus Group, we have seen overseas claims stabilise as we focus on cost containment,” she said.

Patients occasionally wish to be treated near families at facilities outside either of Argus’s networks.

“In these instances, we contact the hospital to establish a relationship with the aim of bringing them into one of the networks,” she said.

BF&M president John Wight also confirmed that the use of overseas provider networks was common practice.

“If a patient is referred by his or her practitioner in Bermuda abroad to a practitioner or facility that is not within BF&M’s provider network, which is rare, BF&M works with the referring physician to locate an appropriate alternate. The reason for this is to reduce potential patient out-of-pocket expense as much as possible.”

Added Mr Wight: “BF&M doesn’t select the facility that the patient goes to. BF&M health insurance members and their referring physicians may choose any facility or practitioner abroad.

“However, the coverage type the member has purchased does dictate benefits, and thus one facility may be more appropriate than others.

“Prior to care abroad, BF&M confirms benefits directly with the member to ensure our members and their practitioners make an informed decision about where care will be received.”

According to Naz Farrow, chief operating officer for health at Colonial Group, the insurer has maintained a preferred provider arrangement in the US since 1995.

“They are very commonplace now, so I doubt they will become more commonplace,” she added, describing the policy as a means of obtaining affordable care.

Colonial is part of a preferred provider organisation in the US representing “dozens of insurance companies and millions of patients” — enabling the company to negotiate a wide range of discounts.

“The hospitals also need to be accredited with the provider organisation, which means things like medical malpractice insurance has to be in place and that the hospitals meet high standards of care.

“Due to changes caused by ObamaCare legislation, [which] have had a direct and indirect impact on access to US care [and] the cost and management of care, we resisted the urge to cut benefits and restrict access to overseas hospitals. We worked hard with our overseas providers to make sure we got access.”

<p>‘We’ll always have to rely on overseas care’</p>

Bermuda’s health insurers maintain a “network” with overseas clinics, according to the Bermuda Health Council, in a bid to curtail the Island’s mounting costs.

Jennifer Attride-Stirling, chief executive officer of the Council, said: “Bermuda will always have to rely on overseas care because it’s impossible for any small community to have highly specialised medical care within its borders.

“For this reason, all insurers cover medical care overseas — including public plans like HIP [Government’s Health Insurance Plan].

“They do so as supplemental benefits, so they vary in what they cover and where. All payers have provider networks overseas or medical assistance providers to help secure better prices at quality hospitals — this is in the best interest of both patients and insurers, as quality care at good value helps to keep patients healthy and premiums down.”

Nevertheless, she added, Bermuda continues to struggle with the amount of healthcare dollars exported overseas — more than $100 million in 2013.

“When this is medically necessary, there is no question as to its benefit,” she said. “But it’s unclear whether all of it is warranted or truly providing value for money. The Health Council is currently analysing claims to gain better understanding of the trends.”

According to industry sources, United States hospitals need assurances that they will be paid for their services before accepting patients from abroad.

Before insurance companies developed networks, US facilities demanded guarantees of payment. Local insurers then turned to preferred provider organisations such as MultiPlan, Beech Street Network and UnitedHealth Group to negotiate discounts.

However, recent changes in the US such as the Affordable Care Act have cut margins for US hospitals — resulting in a closer scrutiny of the deals offered to patients from other countries.

This stands to affect Bermudians travelling to the US for medical care, as prices rise and limits could be imposed on access to special preferred provider organisation rates.