Any health care consortium like the controversial two-tiered health care network engineered by health insurance giant Blue Cross Blue Shield may run up against different regulations. A new package of bills would require full disclosure of how hospitals and doctors get included in tier one and why others are excluded and to make sure that hospitals that serve low income people are in tier one. The state Assembly Regulatory Oversight Committee chair is Assembly Reed Gusciora. He spoke with NJTV News Anchor Mary Alice Williams.
Williams: Thanks for being with us. What is your major concern with Horizon’s OMNIA health care plan?
Gusciora: New Jersey requires that health care plans be adequate and also in the public interest. The OMNIA plan is neither. It’s partially for urban hospitals and in the city of Trenton both hospitals were arbitrarily deemed tier two by Horizon. It excludes cardiac care, trauma and maternity care. There’s no other tiered hospitals in the county that cover those services.
Williams: So what’s the fear? That this would force those hospitals that are in tier two out of business?
Gusciora: Yes, I think in effect Horizon has gone to select hospitals without telling anyone else. We will pay you less reimbursements, we are going to send you more customers because we’re going to in effect put out of business anyone that’s a tier two or lower hospital.
Williams: Let’s talk about your set of bills that have passed through committee. How would they require hospitals to disclose, or what would they require hospitals to disclose?
Gusciora: We require Horizon to disclose their criteria, how they selected the hospitals in tier one or tier two categories. In the city of Trenton you have a hospital, Saint Francis, who has gotten quality assurance awards, but yet Horizon itself has left it at the cutting floor.
Williams: So these stipulations are retroactively applied to the current OMNIA plan, not just future tiered networks?
Gusciora: It puts all the hospitals on an even playing field and it requires that insurance plans disclose how they select the hospitals and then after that consumers can make their choices for which plans they’re going to pick. It’s cynical that Horizon advertised the OMNIA plan without disclosing person to person, especially in the urban areas, that they will not have accessible health care in their midst.
Williams: So, let me ask you that again, so you would require the current OMNIA plan to make these disclosures?
Gusciora: Yes, and I think that’s fair and that’s in the public interest and it’s also something that the Department of Banking and Insurance should be ensuring that these health plans are adequate. The Christie administration has been largely asleep at the switch in allowing Horizon to make public health care policy without any oversight by the state.
Williams: One of these bills is aimed at making sure low income patients are adequately served. Is there evidence that Horizon’s OMNIA plan won’t cover them?
Gusciora: To this day they won’t. If you have an OMNIA plan in the city of Trenton or a state worker and you have cardiac care issues or trauma issues or even maternity issues you have to go outside the county to get tier one services.
Williams: Should health care be decided by health insurance companies as opposed to doctors?
Gusciora: Absolutely not. I think that the Department of Banking and Insurance should take a more active role. Are there too many hospitals in the state? Probably. Should efforts be made to consolidate them? Yes. But should the insurance company themselves make those decisions or should the state step in? I would rather have the state to do that.
Williams: Do these bills have enough momentum to actually get to the governor’s office and desk and get signed into law?
Gusciora: Well, it brings public awareness as to the pitfalls of having a plan like OMNIA, but in the meantime we’re going to be pushing the legislation. We hope that Horizon does the right thing in the meantime and open up their doors for inspection, so to speak, so that people know how they selected these clients.
Williams: Thank you for being with us, chairman.
Gusciora: Thank you, Mary Alice.