Two health care giants are in a contract dispute. This Austin family is caught in the middle.
Jan. 3 was a weird day for Leslie McGuinness-Monclova, a parent and UT Austin employee.
Her dad reached out to her and said he saw her on TV. A friend did, too.
She was on a testimonial advertisement for Dell Children’s Medical Center, where her son, Tavi, had received life-saving treatment for anemia over the last couple years. In the 30-second spot, she speaks to the quality of care her son received. Tavi beams at the end, “My doctor is the best!”
Hours later, McGuinness-Monclova got an email from Ascension, the hospital network that runs Dell Children’s, saying she may have to find her son — a literal poster child for the hospital, she jokes — a new health care provider.
McGuinness-Monclova is one of thousands of Central Texans who are unsure of their health care options as Ascension renegotiates its contract for health care payments with Blue Cross Blue Shield of Texas, the state’s largest insurer. If they don't reach a deal by the end of the month, at least 66,000 customers may have to pay more out of pocket for specialized care. Many have been frustrated by the lack of communication about what's going to happen next.
Days after getting that email, McGuinness-Monclova said the TV spot featuring her son was replaced with a different one. She said she did the ads "in good faith," because of the level of care doctors took helping her son with his rare form of anemia, a condition in which a person's immune system attacks their red blood cells.
"Dell Children's is only in Austin," she said. "And we're not going to be able to utilize Dell Children's if this policy comes to pass and they are no longer in network.”
McGuinness-Monclova said she understands these negotiations are fairly common, but the lack of information from UT, her employer, and H-E-B, her husband's employer which also uses Blue Cross Blue Shield (BCBS), is frustrating.
If the negotiations fail, she could have to go as far as Temple or Houston for Tavi's checkups.
Neither Blue Cross Blue Shield nor Ascension would make anyone available to speak to KUT about the process or patients' concerns for this story.
Ascension said in a statement, “without a commitment to reasonable terms, our current agreement with BCBSTX will end” after this month. All told, Ascension runs UT Dell Medical Center, Ascension Seton Medical Center and dozens of clinics across Central Texas — 54 facilities, by its count.
BCBS said it is “negotiating in good faith and committed to reaching an agreement that will continue to give BCBSTX members access to Ascension facilities at a fair price.”
Continuity of care
It’s important to note, that not every one of those 66,000 Blue Cross customers (or their dependents) would be out of network on Feb. 1.
Jolie Sanchez, a patient advocate who helps people navigate health care plans and insurance policies, says Texas' so-called continuity of care laws require an insurer or a hospital to keep a patient in network if they're undergoing life-saving treatment.
“Ascension has said that if they're currently in treatment for anything, for pregnancy, some life-threatening illnesses,” she said, "they can continue their care through Seton, and if they're mid-treatment, they will not be kicked out of the system.”
"I worry if this deal is not reached, there's going to be a lot of people surprised by this."Jolie Sanchez, patient advocate
If a patient is at 24 weeks of pregnancy and their OBGYN is at an Ascension facility, the patient will be covered through delivery all the way through post-partum care and the six-week checkup.
Patients with an acute condition, a disability or a life-threatening illness, like cancer, won't be dropped from their treatment immediately in the event Blue Cross and Ascension can’t reach an agreement.
Blue Cross has said repeatedly that it does not bill for trauma care, and that customers can get emergency care covered, even if it's at an out-of-network hospital.
But Sanchez is concerned the shift will still impact care, as Ascension hospitals provide the highest level of care in Central Texas for things that aren’t necessarily emergency care.
“Seton is the only level one trauma center, and then Dell Children's is obviously the best children's hospital in Central Texas,” she said. “And so many people depend on that and their specialists.”
And, Sanchez said, it is possible some BCBS customers may get kicked out of network. If that's the case, she said they may have to appeal that decision through their insurer. A perennial problem she faces is that people don’t often pay attention to their insurance until their coverage changes — sometimes drastically.
“I worry if this deal is not reached, there's going to be a lot of people surprised by this," she said. "So ... I'm hoping people are starting to to pay attention to this."
Sanchez urges customers under Blue Cross Blue Shield to reach out to their insurer to determine whether that’s a possibility.
Behind closed doors
McGuinness-Monclova said she doesn't know if Tavi's care would or wouldn't qualify under continuity of care laws. Tavi's receiving treatment that is life-saving, but it's not emergency care. She fears she'd have to pay out of pocket for checkups with a hematologist.
McGuinness-Monclova said she's fully prepared to make the trek to Houston’s Texas Children’s Hospital, rather than spend thousands on out-of-network coverage.
While she understands these negotiations often take place behind closed doors, she says Ascension’s handling of this suggests “the left hand doesn’t know what the right hand is doing,” she said.
“It doesn't seem like it has anything to do with health care and people, and I thought health care is people-centered.”