Is Your Facility a Part of Your Hospital’s Preferred Provider Network?

by Tim Gieseke MD, CMD

In the August 1st edition of the WAVE, I wrote an article about Developing Meaningful Objective Metrics to help facilities narrow their network of post-acute nursing facilities {providers) assuming that the quality of the facilities’ performance would be the key issue.  In my area, I was aware that Kaiser had a preferred provider network, but was not aware that the 2 other local hospital systems had developed their own networks. I found out about one network from one of the preferred facilities’ intake coordinators (a point of their pride) and I just found out this week about the other hospital system having set up their network.  Both hospitals had done so without any public knowledge that it had occurred. Surprisingly, a facility that varies between 4 and 5 stars where I’m Medical Director, was not even contacted to be a part of any of these networks, and they are the only facility in that part of our county.

I know that hospital systems have been given the authority to narrow their networks by CMS, but I had hoped it would be more public and on the basis of verifiable and public quality measures.  In addition, I have wondered how these hospital systems direct their patients to their network while honoring their patients’ right to choose the facility they prefer.

This week, I had 3 examples where this right may have been compromised.  In one case, a Medicare patient’s wife requested transfer to one of my 5-star facilities (out of network since it doesn’t accept Medi-Cal patients). My patient’s wife told the hospital case manager that this was the best facility in the county based on her prior rehab stay.  However, her daughter then discovered that the hospital case manager had only broadcast the inquiry/request for rehabilitation to the facilities within their preferred network. In another case, a facility employee wanted her hospitalized father-in-law to be sent to her out-of-network 4-star facility, but the hospital case manager informed him that this wasn’t possible since that facility was full (which wasn’t true).  The final situation is that of a colleague whose wife is on Medicare and scheduled to have elective surgery. During the preoperative consultation, the surgeon told them she would be going to a network SNF after surgery, without asking her preference. My colleague was shocked, since his wife had previously had a good recovery at our 5-star SNF and would prefer to have rehab there.

In the latter situation, I suspect that the medical staff has been told what facilities to recommend to their patients, but this disappoints me since most of them have never set foot in these facilities nor are they aware of their publically available quality metrics.

At a time when organized medicine is saying we deliver patient -centered care, I find these business developments very discouraging with some of the implementation tactics potentially compromising a patient’s right to choose the facility that’s best for them.

I hope that my local experience is an outlier, but I am concerned that this local experience may be the tip of the iceberg.  

When a hospital’s staff clearly violates this right, we need to document the infraction and put acute hospital leadership on notice that this is not acceptable.  

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