MINNEAPOLIS -- Children's Hospitals and Blue Cross Blue Shield of Minnesota are yet to reach a deal on a new contract, raising the specter the state's largest pediatric specialty care system will become a costly out-of-network provider for BCBS.
Patient's families also face the reality of switching providers, or paying significantly more for care.
"The stress that it has put on parents is a stress that is not fair," Melissa Jaeger, whose son Leo is being treated at Children's for a rare form of cancer, told KARE.
"Yes we need to fix a broken system, and I’m not denying that. But at the end of the day all of us as families are just trying to save our kids lives, so we can bring them home."
The current deal expires at 12:00 a.m. on Wednesday, July 5 and affects both privately insured BCBS patients and those who are covered by a Medicaid plan that the Blue Cross HMO runs on behalf of the State of Minnesota.
"They negotiate deep discounts on our rates, and for in-network providers they cover a higher percentage of those costs," Marc Gorelick, the CEO and President of Children's, explained.
"If we are forced out of network, then patients with Blue Cross would not have access to those deep discounts, and they would be responsible for a higher percentage of the cost."
Gorelick said Children's wanted to negotiate separate contracts with Blue Cross for Medicaid and privately insured patients, but that the insurance company insisted on lumping them together.
And Medicaid has been a sticking point, because Children's has already lost tens of millions of dollars treating Medicaid patients due to low reimbursement rates. Gorelick said the Children's network is now under pressure to absorb even more unreimbursed costs.
"We’ve had no increase in our Medicaid reimbursement rates for about five years. And back in 2015, which was the last year we have this data for, we lost $82 million on Medicaid."
Other pediatric specialty care providers have said they're willing to take on displaced Blue Cross customers as patients.
For instance Shriners in Minneapolis reminded parents Monday that hospital is still an in-network provider.
"We have long provided pediatric critical patient care in this community to patients will all insurances, including Blue Cross Blue Shield, and we are here and available to those with Blue Cross coverage," Charles Lobeck, Shriners Hospital administrator, told KARE.
"It’s unfortunate that the finances of health care now potentially disrupt so many lives, particularly lives of kids."
But it's important to note that Shriners specializes in certain areas of pediatric care.
"Our focus is mainly orthopedics, bone and joint problems," Dr. Cary Mielke, Shriners Hospital Chief of Staff, explained.
"We take care of fractures, infections the musculoskeletal system. We see a lot of children with neuromuscular problems such as cerebral palsy, spinal bifida and muscular dystrophy."
The University of Minnesota and Gillette Children's Hospital would also be expected to absorb some of the Children's patients if there's no deal reached with Blue Cross.
But, considering the scope and scale of services offered by Children's, finding alternatives is easier said than done.
"Hospitals like Shriners provide outstanding care for a very narrow range of patients," Gorelick, the Children's chief, remarked.
"With over 60 subspecialties here we provide really comprehensive care that would be impossible to replace for those Blue Cross Families if we were forced out of network."
In the case of little Leo Jaeger it took an incredible effort to find a treatment that worked and gain all the clearances necessary to make it a reality.
He was diagnosed with Langerhans cell histiocytosis, which first showed up as bumps on his head at the age of six months. Leo didn't respond to traditional chemotherapy, but had a genetic mutation that made him a candidate for a drug that's normally prescribed for melanoma.
"The doctor had to petition Children’s to get him genetically tested several times because that’s usually not covered by insurance, so he had to petition to get him tested," Melissa Jaeger explained.
Children's had to gain approval from the FDA, and enter a contract with drug manufacturer Novartis to create a treatment plan for Leo. That includes regular monitoring to guard against collateral damage to his other organs.
The good news is that he has responded well to the drug and all traces of the cancer have been removed from Leo's brain. The sobering part is that the cancer can return in just a few days if he goes without the drug.
"We've been told it would take at least three months to get this course of treatment, with the drug, approved for a different hospital system," Jaeger said.
"People's lives are at stake."
Blue Cross on Monday didn't respond to inquiries from KARE.
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