‘Hoops & Hurdles’ of the for-profit health insurance industry with Dr. Glenn Hurst

This is a personal story from CCI member Dr. Glenn Hurst, Minden IA, shared with us as part of the Hoops & Hurdles campaign to call out for-profit health insurers. Share your story and learn more about the campaign here.

A patient came into my office recently and told me his family had received some bad news. They were being forced to change to a new health plan for his wife and the children and it meant they could no longer see me in my rural clinic. It seems, in order to save money, his wife’s employer had picked a new insurance plan. This plan had a closed network.  

The closed network meant the family could only go to certain doctors, hospitals, or other providers unless they were willing to pay out-of-pocket for the provider of their choice. Of course, paying out of pocket defeats the purpose of having insurance. I was not on the list of providers they could pick. 

Network participation is one of the hoops providers must jump through whenever they appear. These networks are formed by health systems, provider groups, insurance companies, and other entities. I honestly have no idea which ones I am in, how I got there, or what kept me out of the one his family had to choose.  

For a provider to participate in negotiations for insurance reimbursement, shared risk, and quality measures for every insurance package, it would require another full-time employee, another hurdle. So, most providers engage a credentialing company to do this for them. That is the case for me and just about every provider I know.  

In this case, we made a special effort to jump through the hoops of joining this network. We argued that the change in providers would have resulted in several hardships for the family. The nearest in-network provider was 40 minutes away, whereas; my office was 10 minutes away and directly on the way to and from their school. My office was also 3 blocks from their pharmacy. I was rejected because the plan already had a participating MD within 60 miles.  

So many of the hurdles of our competitive healthcare system were unmasked by this one employer’s decision. The sad result of this change rippled across their relationships with each other and in the community. The father could still see me because he had different insurance through his work so they had to split up where they got their care. His kids, whom I had cared for since they were very young, now had to go form a relationship with a new provider in their awkward teenage years.  

It showed how healthcare markets undermine the very essence of Family Medicine; a provider who understands the relationship of the family and its medical needs. It demonstrates that patients really don’t have choice in their provider, employers do.  

It affected our small community’s survival by removing local spending from the community’s economy. It made remaining in our community more difficult to justify for this family. It led to the loss of prescriptions and foot traffic at the local pharmacy and our rural Main Street. 

A just healthcare system would have met this family’s needs and given them choice in where and with whom they get their care. It would have made the quality/convenience of the patient's experience and the outcome of their care be the driver of the market.