LAST year, after U.S. Rep. Gabrielle Giffords was shot in the head in front of her constituents in Tucson, Ariz., the public witnessed some of the very best brain-injury care in America. Memorial Hermann Healthcare Systems hospital in Houston, where Giffords went for her acute rehabilitation, is world-renown for traumatic brain injury treatment. Now, Memorial Hermann hospital is locked in a $1.1 million lawsuit with one of the largest medical insurers in the nation, United Healthcare, over disputed claims.
Meanwhile, in New Jersey, startled health insurance members recently received letters informing them that the local hospital had just cut ties with their insurer. One concerned man said, “I am in a panic mode as my wife is [pregnant and] due in a couple of months. This is a last-minute change for both of us. The effective date is Feb. 15, which is such a bad deal for Jersey City residents.”
The letter, dated Jan. 15, reads in part: “Jersey City Medical Center no longer participates with Aetna. We want to let you know that as of Feb. 15, Jersey City Medical Center is no longer part of the Aetna network. However, we will continue to negotiate in good faith toward reaching an agreement.” The letter from Aetna continues: “What this means for you: Starting Feb. 15, 2012, only members in plans that offer out-of-network coverage will continue to have access to this facility.”
The letter is a lie. Despite the health insurance company’s implication that their members have no choice but to go to some other hospital far away, the patients can still seek treatment at the Jersey City Medical Center. The fact is that the health insurance company simply refuses to pay Jersey City Medical Center the going rate for hospital services. The health insurance company wants steep discounts that the hospital says it cannot afford.
This cut-throat game of medical economics is being played out all across America. On Guam, it manifested recently when the Guam Memorial Hospital declared that TakeCare health insurance would no longer be accepted as payment for medical services. Reportedly, TakeCare had consistently refused to pay GMH more than $500,000 in past-due bills dating back to April 2011.
Because of a failure to resolve payment despite monthly negotiations dating back to last summer, the GMH board decided that starting March 2012, TakeCare patients would have to pay cash for hospital services and seek reimbursement from their health insurer directly.
GMH observers claim that many local insurance companies routinely reject even legitimate claims from the hospital, thus forcing GMH to seek expedited payments even with deep discounts. "Often, hospitals – who have already expended money to provide the services – are willing to accept less than they are owed from insurance carriers just so that they can pay bills," a mainland hospital expert said. "This is one of the reasons why many of our hospitals are in trouble."
Meanwhile, the GMH billing department is also struggling. According to the FY2011 hospital audit report by Deloitte & Touche, “Managing the growing Patient Receivables has been made more difficult because of the current government-wide freeze on hiring. The three departments’ (Patient Affairs, Patient Registration and Medical Records) duties and responsibilities are billing, collection and clearing the Patient Receivables. However, due to the shortage of personnel, the employees, on a daily basis, had to juggle their time between the various tasks, with certain of these necessarily taking secondary or even tertiary priorities.”
So in the face of all these troubles, I think we should start achieving solutions. GMH must be honest with itself and start removing the 200 excess personnel who don't provide direct patient services or collect payment. Let's start in the non-functional Personnel Office. If there is a government-wide hiring freeze, then we don't need people to not hire folks.
Then, I say that all Guam health insurance companies should be required to pay for the privilege of doing business on Guam. I call on the Guam Economic Development Authority to immediately suspend the reckless qualifying certificate program that allows local insurers not to pay their fair share of taxes. At the current 4 precent rate, GovGuam would realize approximately $16 million annually that could go towards health insurance regulation and medical care for the poor. Let’s hope our governor and Guam Legislature can make that rational business decision.