From Sunday, August 24, 2003, issue of The Albuquerque Journal

Blue Cross, Presbyterian Nix Deal

By Winthrop Quigley
Journal Staff Writer

About 35,000 Blue Cross and Blue Shield of New Mexico customers in a four-county area, including Bernalillo County, will have to find new doctors, a new insurance company or pay more for health care starting Jan. 1.

Blue Cross and Presbyterian Healthcare Services had been holding out hope that they could successfully negotiate a new contract.

But the two agreed Friday that they could not make a deal and would let their current five-year agreement expire Dec. 31.

The Blue Cross customers effected are in Bernalillo, Torrance, Valencia and Sandoval counties.

The agreement under which Blue Cross paid Presbyterian for caring for its customers was originally set to lapse Sept. 30. That date has been pushed back to the end of the year to help patients transition to new health-care providers or to a new insurance company.

"We made a good-faith effort to continue our relationship with Blue Cross," said Presbyterian chief executive officer Jim Hinton. "Both parties agreed we can't get it done."

Blue Cross and Blue Shield president Liz Watrin said, "Obviously, we are disappointed with the outcome, but (both companies') main focus is to make sure that members and patients are taken care of in the transition."

The companies will execute contracts that allow Blue Cross members outside the four-county area to continue using Presbyterian facilities and providers.
"In most regional communities, there really isn't any choice for patients, so we mutually agreed in areas where there is no choice, we have to work out an acceptable arrangement," Hinton said.

Presbyterian operates in nine communities outside the Albuquerque area, including Ruidoso, Socorro, Carrizozo, Tucumcari, Clovis, Cimarron, Angel Fire, Española and Springer.

Blue Cross customers have these options:

Find new health-care providers who accept Blue Cross and Blue Shield payment. Watrin said that Presbyterian represents seven percent of Blue Cross and Blue Shield's provider network and 250 of the 3,000 physicians to whom the company provides insurance payments.

"Out of 11 hospitals (that accept Blue Cross payments in the area), two will be terminated," she said.

Change insurance companies. Presbyterian offers its own insurance plans and accepts payments from several other companies, among them Mutual of Omaha, United Health, Aetna, First Health and a number of University of New Mexico health plans.

Continue to use Presbyterian but pay for services out of their own pockets. Some Blue Cross plans will pay to any provider a maximum allowable charge, with the patient required to pick up any charges over that amount. Other plans will not pay for services provided outside of a network of providers Blue Cross designates.

Both health-care organizations are bracing for a flood of calls from upset customers and have prepared customer service representatives to handle them.

There are some cases where patients who require continuing care in the Presbyterian system after Dec. 31 will get it, Hinton said. If, for example, a pregnancy continues past the contract's life, the patient can continue using Presbyterian with Blue Cross insurance, he said.

The impasse has also angered insurance agents.

They "are really hacked off with what's going on," said Thom Turbett of the Independent Insurance Agents of New Mexico.

"It gives (agents) less choice for their clients," he said. "It also puts thousands of businesses in a position to have to make plans when they can't access the doctors they've been used to accessing for years."

Hinton said the reason the companies are parting ways was that Blue Cross and Blue Shield would not pay enough for Presbyterian services.

"We have been on a path of investing in programs and services that people want for the last five years," he said. "We simply can't enter into business relationships that don't allow us to invest in patient care."

Watrin said Blue Cross has been trying to keep its premiums affordable. "The problem in the health-care industry today is that employers and members are being hit with double-digit rate increases, just for the cost of health care," she said.

Though both companies have done business with each other for decades, their relationship has been rocky before. The companies have canceled their agreements three other times since 1984, according to Presbyterian.

Have questions?

Blue Cross and Blue Shield members can call the number on their membership cards.

Patients with questions for Presbyterian can call 923-5999 or (866) 869-6224, or visit the Presbyterian Web site, www.phs.org.

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