Newspaper article The Record (Bergen County, NJ)

Senate Right to Review Horizon's Motives

Newspaper article The Record (Bergen County, NJ)

Senate Right to Review Horizon's Motives

Article excerpt

Recently, state Senate President Stephen Sweeney, D-Gloucester, announced he would call for legislative hearings to examine Horizon's controversial OMNIA tiered network plan and its recently launched Medicare Advantage product. As a surgeon working at both Tier 1 and Tier 2 hospitals, I applaud the Senate president for taking a second look at the OMNIA network and the impact it's had on New Jersey's healthcare system and patients.

In 2015, Horizon Blue Cross Blue Shield of New Jersey launched the controversial OMNIA plan, categorizing hospitals and providers in its network into two groups – Tier 1 and Tier 2. Patients in the OMNIA plan were pushed to visit Tier 1 providers and hospitals with lower co-pays and out-of-pocket costs.

Significantly – and tragically – OMNIA's tiers have nothing to do with healthcare quality, but rather everything to do with market share. The hospitals in Tier 1 are mostly large chain-type hospitals, including Hackensack Meridian and Barnabas Health Systems. The Tier 2 hospitals, while mostly community hospitals, include some of the highest quality, most affordable hospitals in the state — including Holy Name Medical Center and St Luke's Warren Hospital, two of only three CMS 5-star hospitals in New Jersey.

As a Tier 1 surgeon, I have seen firsthand the confusion and chaos that patients experience in dealing with OMNIA's tiered network. Many patients have been forced to find a new doctor or hospital – even in the middle of treatment – or pay a much higher copay to be treated by their trusted, and in many cases higher rated, doctors and hospitals. Horizon OMNIA – and now its Medicare Advantage plan – undermines our healthcare system by making it harder for patients to get quality, affordable care at some the state's highest performing hospitals and practices.

Perhaps the most disturbing aspect of Horizon's plan has been the company's complete lack of transparency in determining the criteria for their new tiered network. Clearly, quality of care and affordability did not play a role, as many of the Tier 2 providers far exceed Tier 1 providers in those categories. There was no public process or known criteria by which hospitals and physicians were assigned to a tier, nor is there any public path to move to another tier. …

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