When contract negotiations went sour between Presbyterian Health Plan and the University of New Mexico Hospital, more than 13,000 Presbyterian plan members were denied access to providers and services at UNMH.
On Jan. 1, the restrictions went into effect, and overnight, thousands of insured New Mexicans were made to choose between their existing doctor and insurance plan. Three months later, providers and patients are struggling with the disruption in coverage.
The story is nothing new, and perhaps that’s why the plight of these displaced patients went underreported. It’s par for the course in private health insurance: patients made to leave their beloved providers, because insurers and hospitals disagree on reimbursement rates or other issues.
Just ask any of the thousands of Lovelace Health Plan members who were forced to leave ABQ Health Partners.
The abuse of New Mexico’s insured population is so commonplace, one could argue it isn’t newsworthy. I disagree.
In today’s America, saying, “13,000 patients were affected by the greed of for-profit medicine” may draw little more than a groan from many. But aside from the regularity of such offenses, numbers are an impersonal way to express human suffering.
Numbers can’t tell the story and situation of every individual harmed when health care is built around profits and not people.
As a third-year medical student, I have had the opportunity to meet the families affected by this “new contractual relationship,” as described by Presbyterian.
While working with a pediatrician who mostly cares for children living with physical and intellectual disabilities, I was shocked to see how many patients had to cancel their appointments. In one morning, only two families were able to keep their appointments because of the coverage change. One family actually had Presbyterian Medicaid insurance, but scraped the money together to pay out-of-pocket because according to the parents, their pediatrician was like a member of the family. This was no small expense for a foster family with limited means.
Why are we allowing this to happen? No other developed nation — all with single-payer or nonprofit government-regulated insurance — would allow their citizens to be mistreated like the Presbyterian Health Plan members.
What is most shocking is that many of the Presbyterian families forced to leave their provider have publicly financed health insurance, through Medicaid. In other words, the health insurance of the child mentioned above is paid for by the same tax dollars as the child in the adjacent exam room who has Medicaid through another managed care organization, such as Molina Healthcare.
In New Mexico, managed care organizations, such as Presbyterian, administer Medicaid insurance only after siphoning off profits and incurring overhead and administrative costs. In return, Medicaid recipients are forced into narrow networks that restrict choice of services and providers. These patients and the care they receive are subject to the whim of contract disagreements.
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And while Presbyterian Healthcare Services goes to every length to advertise their status as a not-for-profit healthcare system, Presbyterian Health Plan is very much a for-profit endeavor. The insurer reported profits of $38.4 million in 2012.
Stories of managed care exploiting illness for profits are heard around the country in states where traditional state-run Medicaid programs have been converted into systems of competing private insurers.
These states, including New Mexico, were sold on the idea that managed care could save money and slow healthcare inflation. After years of exponential increases in spending, widespread abuse, fraud and diminishing public support for Medicaid managed care, perhaps New Mexico needs to reevaluate the role of profit in public insurance.
The times are changing. States such as Connecticut and Oklahoma have taken back their Medicaid programs and ended the role of private insurers. In the meantime, I hope Presbyterian Plan members are able to fall back on their widely publicized gym memberships, which also went into effect on the first of the year.
