Argus drops US children’s hospital from preferred list
Paediatricians and families have been left reeling after BF&M and Argus Insurance removed Boston Children’s Hospital from its preferred providers list.
However, Pete Lozier, executive vice-president and group head of benefits at BF&M and Argus, said the top-ranked hospital remained part of the firm’s overall provider network.
He confirmed that BCH was not included for customers on preferred provider network plans, but added: “Customers who are not on a PPN policy retain full access to BCH, with no change to their coverage.”
The comments came after Stephen West, of Wee Care Paediatrics, posted on his practice’s Facebook page saying Argus, one of the island’s leading health insurance companies that has merged with BF&M, had made a “recent change” in coverage for children.
He said that the move meant families previously covered could pay 50 per cent of charges, and that he and other children’s doctors had not been directly informed — only finding out after referrals to the hospital were rejected in May.
He called on families to reach out to Argus to let them know “this was not a move made in the best interest of Bermuda's children”.
Mr Lozier said Argus and BF&M prioritised “high-quality, evidence-based care” while protecting affordability and long-term viability of healthcare.
“We absolutely understand that healthcare decisions are deeply personal — particularly when they involve children.
“It is therefore unfortunate that some providers chose to share information on social media instead of reaching out to us directly for clarification. This has caused unnecessary distress and confusion within the community, especially since many of the statements being circulated are inaccurate and misleading.”
Boston Children's Hospital is the main paediatric training and research hospital of Harvard Medical School at Harvard University.
Mr Lozier said customers or children already undergoing treatment at BCH would continue care uninterrupted.
“No one is required to change providers mid-treatment due to this network change,” he said.
Dr West told The Royal Gazette: “When we tried to do referrals for patients to BCH after May, they were rejected.
“Families will potentially need to pay 50 per cent of charges or potentially need to look to other centres.”
CG Insurance said its Major Medical Health plans gave access to international healthcare, with its US network including more than 1.4 million providers.
It said members on Major Medical coverage had recourse to top-ranked US hospitals, reimbursed at 100 per cent, including Boston Children’s Hospital and others in the city such as Brigham and Women’s Hospital, Lahey Clinic Hospital, Massachusetts General Hospital and Dana-Farber Cancer Institute.
A spokeswoman added: “CG recognises the importance of access to quality healthcare overseas and works collaboratively with local providers to ensure that, when needed, referrals can be made seamlessly and efficiently.“
Mr Lozier said in response that there was no across-the-board 50 per cent cut.
Asked what the potential impact was for families needing care at the hospital, Dr West added: “Boston Children’s Hospital is our primary referral source in a lot of cases.
“At present, due to the incredible relationships that we have with the specialists at BCH, many times we will reach out directly to the physicians to get their thoughts and opinions via an e-mail or phone call in a very timely manner. Sometimes this will mean that the patient, in the end, can be fully managed here on island and may never need to go to BCH.
“This only happens at present because the physicians in Boston know and trust the paediatricians in Bermuda because of our many years of communication. We would lose this level of service for a time as we would need to develop these relationships with another centre of excellence.
“I have heard from a couple of the other paediatricians on island and their feeling is the same — it would be an incredible loss for Bermuda's children.
“Many families are very upset.”
Dr West said there were families who had been given appointments by BCH who would have to switch because of extra charges.
He said there are other "centres of excellence for paediatric care“ that his practice used.
However, he added: “Definitely we have the best relationship and the most volume with Boston Children's Hospital. And it is that relationship which often leads to quicker answers, a smoother process in getting the patient assessed at the tertiary centre, the ability to ask questions and potentially be able to manage the case fully in Bermuda. And this is what we will lose for a period of time if we are not allowed to use Boston Children's Hospital.
“Also of note, at present, all of our paediatric cardiac ECHOs and EEGs are read at BCH under an arrangement with the Bermuda Hospitals Board and BCH.”
The Bermuda Health Council said it advocated for greater transparency from insurers, “merged or otherwise”, in reviewing their services.
A statement added: “They will determine where they can get the best discounts, the most significant rebates or the best currency conversion rates.
“However, as efficiencies and optimisation is reviewed, there is still a responsibility for transparency. In general, transparency in such change shouldn’t have to come from randomly bumping into a post on social media.
“There has to be more proactive communication so everyone has a chance to make informed decisions for themselves and their families, instead of sometimes feeling trapped by someone else deciding on your behalf without your input.”
The council said changes to BCH as a preferred provider “highlights how insurance companies often may choose partners based on their own clinical, business or cost reasons.
“However, as consumers, the ones buying health insurance, it's important we all get clear explanations about why these choices are made.
“There is a lot of work that has to be done to help our residents navigate not only the local healthcare system but also to understand all the various networks that are at our disposal overseas.
“While there should never be an expectation of unlimited options, the options that are available and used should be aligned with the standards we set as a society, and what we have shown that we are willing to pay for.”
Ricky Brathwaite, the chief executive, said he understood concerns around paediatric care, having had an insurer direct him to another provider over his “strong preference based on a hospital’s reputation”.
“Although I wasn’t initially happy, the care I received did end up as excellent. Still, it’s important to recognise that insurers might not always make decisions that align with individual preferences for various reasons.
“At the core of any of our companies are people, and they may not always make the best choices, and it’s up to society to hold decision-makers accountable — and that goes for CEOs of regulatory bodies, such as myself.
“So with that said, I’m doubling down on the importance of people asking questions, demanding clear answers and doing their own research to know when to push back.”
He said employers could have say over the coverage offered by insurers.
“For those that are unhappy, it may be beneficial to sit down with your employer or the employers that you are familiar with and ask them to advocate alongside you.”
Mr Brathwaite said the health council advocated for transparency in its monthly meetings with insurers.
“Insurers have shown a willingness to be responsive when such requests have been directly made,” he said.
“On this specific case, while it would be a conflict of interest to advocate for coverage for only select healthcare providers, we are instead focused on establishing a standard that any chosen provider, whether local or overseas, must meet.”
He said the council was working on developing online dashboards showing the rating and metrics behind decisions, adding: “I assume that our local insurers are doing their homework to make sure they aren't presenting substandard care options, but it is always good to have such verified with sound data.
“We at the health council are also working on creating the platforms that intentionally highlight these concerns and provide clearer channels for advocacy, and a patient’s bill of rights that will ground us all in what to expect for ourselves when we are patients.
“We will do our part and ask the specific questions on the coverage of Boston’s Children’s Hospital as it is an institution that resonates with a lot of families in Bermuda who have experienced life-changing care with that institution.
“So there is a cultural component to the explanation as to why there may be policy changes.”
The insurer told the Gazette that BCH has been taken off its preferred provider network as “part of our broader network optimisation strategy, focused on cost-effectiveness, quality outcomes and long-term sustainability of care”.
The PPN was described as an optional tier developed in 2015 in response to demand for more affordable options, with “a select group of high-quality, cost-effective providers, resulting in lower premiums and tailored support for members”.
Paediatric hospitals on the PPN include the Hospital for Sick Children in Toronto, Children’s Hospital of Philadelphia, Nemours Children’s Hospital in Delaware, and IWK Health Centre in Halifax.
Mr Lozier said the claim of a 50 per cent coverage cut for BCH was “incorrect”.
He added: “Coverage levels vary based on the specific plan. PPN plan members may have different reimbursement levels for non-PPN providers, but there is no blanket 50 per cent reduction.”
He also said Dr West’s office had been informed of the change.
“While network configuration updates are standard across the global insurance industry and not always communicated to every overseas provider, in this case Dr West’s office was notified prior to the renewal period.”
Dr West responded that he had “definitively” not been notified of the BCH removal, and said the 50 per cent reduction had been quoted for three recent cases involving his patients.
He said at least one other paediatric office had said it was “blindsided”.
Mr Lozier said BCH was not the only facility affected by the change.
“We routinely evaluate all network providers to ensure alignment with clinical standards, patient outcomes and financial sustainability,” he said.
“BCH is just one of several facilities reviewed in this process.”
He confirmed that the firm had heard from “a small number of concerned members and providers” and welcomed open dialogue.
Mr Lozier also “wholeheartedly” supported the move as being in children’s best interests.
“Our goal is to ensure Bermuda’s children continue to have access to world-class care while keeping coverage affordable for families and the system sustainable for future generations.
“PPN plans still include globally renowned paediatric institutions, and we continue to honour continuity-of-care protections.”
He said the insurer “constantly” reviewed its network.
“If future evidence supports change, we will evaluate it seriously. In the meantime, we remain absolutely committed to transparency, quality and ensuring uninterrupted access to the care families need.”
Mr Lozier added: “We welcome dialogue with our providers and community members. We remain open to future network changes if clinical data and member needs support doing so.
“What we ask is that conversations begin with facts, not fear.”
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