Becky Sigman is worried about her heart valve replacement.
The 83-year-old knows she needs the surgery - her doctor told her as much. The doctor also told her that a conflict between the area hospitals able to perform the surgery and her health insurance could mean hours of travel, possibly out-of-state, for her to receive the care she needs.
"I may be too old for a valve replacement; I don't know," she said. "But if I'm living during open enrollment next year, you'd better believe I'm dropping Humana."
Sigman's doctor, Dr. Kishore Challa, is a cardiologist at Thomas Health System - he performs hundreds of cardiac catheterizations at Thomas each year, but he doesn't perform valve replacements at the hospital. State law prevents more than one hospital system in each county from becoming a designated open heart facility, and that distinction belongs to Charleston Area Medical Center, which dropped its contract with Humana in 2013.
Now St. Mary's Medical Center in Huntington has followed suit, ending its contract with Humana starting Jan. 1. The hospital, one of West Virginia's largest, is the open heart facility in Cabell County.
Most Humana consumers in West Virginia aren't affected by the change. Those with PEIA Humana coverage can still have heart surgery at CAMC or St. Mary's, but for those in southern West Virginia who purchased a plan directly from Humana, the switch means traveling to Morgantown, Ohio or Kentucky for care, or accepting the greater out-of-pocket costs associated with out-of-network care.
"The most recent contract between St. Mary's Medical Center and Humana resulted in much lower reimbursement from Humana than even Medicare pays," said Doug Korstanje, director of marketing and community relations for St. Mary's. "St. Mary's Medical Center decided the overhead to administer the plan going forward was cost prohibitive."
Korstanje said St. Mary's accepts many other Medicare Advantage plans, and the medical center worked to inform its patients about the decision to drop Humana during open enrollment last year. Korstanje said for patients who were not able to leave Humana, the hospital would work with them on out-of-network penalties until a new enrollment period begins and they are able to choose a different plan.
"My daughter called CAMC, and was told they take some Humana - Humana PEIA, Humana Advantage. I've got Humana Gold, and she said she was pretty sure they would take it, but I wouldn't go in there just on that," Sigman said.
Brian Ulery, chief operating officer for Thomas, said the hospital system takes all forms of Humana. Certificate-of-need law prevents the health system from delving into open heart surgery, and Ulery said the monopolies created by current CON law could have widespread implications for patients with out-of-network coverage in need of procedures that only certain hospitals are allowed to provide.
"The state created these monopolies for certain services," Ulery said. "The rationale was that they're expensive programs to put in place, and years ago, many states had CONs in place that severely limited these things. Many states have given them up, though."
Challa said he believes the law should either be reformed so that hospitals like Thomas could establish their own open-heart programs, or that hospitals like St. Mary's or CAMC would be required to accept local patients whose insurance they don't accept for procedures they can't receive elsewhere in the area.
"Healthy competition is good for everybody," he said. "If that is not going to happen through the Legislature, at least doctors like us should have a way to refer some patients, for things like bypasses or heart replacements, which aren't available in this facility, to CAMC or St. Mary's, and the patient should not be penalized for that."
Humana spokesperson Jeff Blunt said the insurer was "disappointed" that St. Mary's chose to leave its network, but that Humana still had contracts with several nearby hospitals, including Thomas, Cabell-Huntington Hospital, Kings Daughters Medical Center and Our Lady of Bellefonte Hospital in Ashland, as well as nearly 400 primary care physicians and 900 specialists in care locations in the region.
"As is always the case, in the highly unusual circumstance that a Humana member needs medical services not available within our network, we will work individually with that person to arrange for and cover care at an out-of-network facility," Blunt said. "It's also important for people to remember that in emergency situations, medical care is always covered at in-network benefit levels at the closest emergency room, regardless of network status."
A legislative bill that would create a process to update certificate of needs standards, House Bill 4365, is currently before the House Judiciary.
Reach Lydia Nuzum at lydia.nuzum@wvgazettemail.com, 304-348-5189 or follow @lydianuzum on Twitter.