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As it seeks to shore up its budget, Oregon Health & Science University is working to manage the flow of patients with out-of-network insurance, a change which could shape where many Oregonians get their health care.
A new policy outlines steps OHSU administrators should take when engaging with patients seeking a service from OHSU, in cases where their health insurer has not contracted with OHSU to pay for that service.
OHSU will do its best to get the insurer to authorize the service and agree in advance to a one-time pay rate, an OHSU spokesperson said in a statement. Only when it is not able to, she said, would the guidance be to refer the patient to a separate in-network provider or facility.
The new policy comes nearly six months after OHSU struck a deal to preserve coverage for 74,000 patients insured by UnitedHealthcare. The contentious negotiations this spring laid bare the tensions roiling under the healthcare industry as costs rise—and hospital systems and insurers both seek to protect their end.
OHSU leaders, for their part, say they need to manage skyrocketing expenses to sustain the institution’s vitality into the future.
OHSU was already following similar processes that it is now putting into policy, the spokesperson said, in line with its responsibility to “(1) prioritize care for patients with plans that we are contracted to serve, and (2) to help financially screen patients and reduce [patients]’ out-of-pocket expenses.”
OHSU appears to be minding its own finances as well. Like other U.S. health systems, it negotiates with private insurers to determine how much those insurers, under the various plans they offer, will pay for services provided to their members. Such agreements determine whether a given service or plan is “contracted” and/or “in-network.”
Insurers that have not forged such a deal with OHSU are likely to pay significantly lower rates, an OHSU presenter, Kristi Cushman, told other staff in a recent video call, which was reviewed by WW. “Sometimes they may not pay us at all.”
This, Cushman added, means higher out-of-pocket costs for patients because the remaining balance gets passed to them. And it also leads to reduced payment for OHSU—especially if the patient has financial assistance, which could mean they pay only a portion or none of the cost.
The presenter added another rationale for the policy: access. Patients are being scheduled months and months out at OHSU right now, she said, and those with out-of-network plans are taking up scarce appointment slots that could be going to members of insurance plans with OHSU contracts.
There are many services OHSU performs that are offered elsewhere in the area, Cushman said, and OHSU should, when necessary, be sending patients to those facilities that are in-network for them. Still, she added, as the new policy gets implemented, discretion is advisable.
“We have a lot of patients that are in our system and already receiving care from us that have these types of plans,” she told staff, referring to patients that might be affected by the new policy. Staff, she said, should seek to follow the new policy, “but we also need to not disrupt patient care, and if we are the only care provider, or the patient is almost done with their treatment, it does not make sense to transfer a patient.”
