Insurance can determine patient destination

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Monday, December 12, 2011
— Where to?

Mercy Hospital and Trauma Center or St. Mary's Janesville Hospital?

When it comes to choosing a local hospital, most Rock County residents will have a choice of the two facilities, but some may pay for the privilege.

People who participate in their employers' group health insurance plans often choose between competing plans that vary in coverage and cost.

Some employers, however, offer a single plan that steers employees toward one provider's network of services.

Ninety percent of the 155,000 Rock County residents reported in 2007 that they had some form of health insurance, according to the state Department of Health and Family Services. At the time, 74 percent said they participated in employer-sponsored plans.

Precisely what percentage of area residents would be steered to either Mercy or St. Mary's is not clear because insurance plans, their costs and their coverage limits vary widely and often change from year to year.

In Rock County, MercyCare insures about 23,000 people, and Dean covers about 20,000.

Many of those people have made their employer-covered insurance decisions with companies that are members of The Alliance, an employer-owned and directed not-for-profit cooperative that helps more than 160 companies manage their health insurance.

The Madison-based Alliance covers more than 83,000 people in Wisconsin, Illinois and Iowa and contracts with thousands of providers for health care services.

In Rock County, The Alliance includes 22 employers that carry insurance on nearly 13,000 people. Alliance members have access to a broad array of health care providers, including Mercy Health System, Beloit Memorial Hospital, Edgerton Hospital, Dean Health System and St. Mary's hospitals in Janesville and Madison.

Nearly all of The Alliance members in Rock County offer their employees a broad network that includes coverage with both Mercy and Dean providers. Only three offer a choice between the network and some other plan, such as an Exclusive Provider Organization plan, that limits patients to one provider or another.

Employees who choose the broad Alliance network can use any provider they want within the network and in some cases pay more for out-of-network services.

In an EPO, however, employees must use providers from a specified network of physicians and hospitals to receive coverage. There is no coverage for care received from a non-network provider, except in an emergency.

Bliss Communications in Janesville, which publishes The Gazette, is one of the three companies in The Alliance that offers an EPO. Employees there can choose between two health care plans:

-- A Preferred Provider Organization plan that offers provider choices in the full Alliance network.

-- An EPO affiliated with Mercy. That plan restricts employees to the Mercy network, but Bliss employees' portion of their premium is less expensive than the premium for the Alliance PPO plan.

Not all employer-sponsored plans offer extensive options such as those included in The Alliance. In some cases, employers that don't self-fund their plans might sign on with a Health Maintenance Organization that restricts employees to particular providers.

Rock County is served by seven HMOs, including those offered by Dean Health Plan and MercyCare, according to the Wisconsin insurance commissioner's office.

In some cases, the choice between one hospital and another has nothing to do—at least initially—with insurance coverage.

Area ambulance crews will serve both hospitals, and patient choice will typically determine the destination.

A patient with MercyCare insurance can opt for delivery to St. Mary's Janesville, and the same is true for patients with DeanCare who want to go to Mercy. In both cases, though, the patient might face higher insurance costs and deductibles at out-of-network facilities.

In certain cases, it will be possible to see Dean doctors at Mercy and Mercy doctors at St. Mary's. The two Janesville hospitals will share on-call privileges for physicians in the specialty areas of ophthalmology, urology and vascular surgery.

While the vast majority of patients choose their hospital destinations, some are in no condition to do so.

That's when the decision is made by EMS responders to transport to the closest facility that can provide the most appropriate care.

Last updated: 7:07 pm Thursday, December 13, 2012

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