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CONTRACT EXPIRING
Almost a third of Las Vegas workers are covered by a group of insurers that is challenging St. Rose Dominican Hospitals over the cost of treatment.
The Health Services Coalition, a group of 24 self-funded insurance plans, is threatening to end its long-standing relationship with St. Rose Dominican Hospitals because the two can’t agree on reimbursement rates.
If contract negotiations break down — a real possibility — almost 30 percent of Las Vegas workers could be forced out of the St. Rose system, which operates three hospitals and two surgery centers (Rose de Lima, Siena and San Martin hospitals, and Durango Outpatient and Parkway surgery centers). Patients would have to find different hospitals to visit or pay for care out of pocket. Health Services Coalition insures about 260,000 patients and provides coverage for the valley’s largest unions, including casino workers, firefighters and police officers.
At issue are the cost and quality of health care. Health Services Coalition claims St. Rose charges too much for treatment and is the most expensive provider in its network.
“We just have a genuine disagreement on the value of the care being provided,” the coalition’s Executive Director Leslie Johnstone said. “The health plans cannot afford to pay the St. Rose rates. If there were quality measures where they were head and shoulders above everyone else, that might be taken into consideration. But we do not see any hospital standing out in its quality.”
The Siena and San Martin campuses are among the local hospitals with the highest number of patient readmissions, according to a coalition study, and Siena outranks most valley hospitals in percentage of C-section births.
St. Rose argues that Health Services Coalition’s reimbursement rates fall below the cost of providing care. St. Rose spokesman Andy North said Health Services Coalition pays the hospitals less than 50 percent of the national average — and the coalition proposes paying even less next year. North said the only price increase St. Rose has asked for is to cover inflation.
It’s impossible to judge the payment rates independently because neither side would divulge the prices being discussed. The groups’ current three-year contract expires Dec. 31.
“We’ve tried to be very reasonable,” North said.
As for quality of care, North said St. Rose leads the state. Indeed, St. Rose ranks above the national average and many of its competitors in treatment of heart attacks and pneumonia, according to Medicare records.
While the providers haggle, patients could emerge as the biggest losers.
Scott Hansen has undergone three surgeries at St. Rose to repair his femur, which he broke in an accident in July. He expects another year or more of treatments and physical therapy. Hansen, a deli owner, is insured by Health Services Coalition under his wife’s plan. She is a server at New York-New York and a member of the Culinary Union.
“I can’t imagine having to find someplace else to go to,” Hansen said. “Plus, I’m comfortable with my doctor. What happens if he doesn’t have privileges somewhere else?”
Patients would be able to receive emergency care at St. Rose regardless of its status in the coalition’s network, but they would need to look elsewhere for elective and nonemergency procedures. Emergency room patients also would be transferred once they are stabilized.
Health Services Coalition is fighting a similar battle with other valley hospitals, but so far St. Rose is the only hospital group to be notified that it may be dropped. The gap in negotiations is widest between the coalition and St. Rose, Johnstone said.
“It is not a foregone conclusion that we will settle with the other hospitals,” she said.
In 2006, Sierra Health Services, then the state’s largest health care provider, and national hospital giant HCA Inc., known locally as Sunrise Health, broke ties following a long contract standoff similar to the one Health Services Coalition and St. Rose are battling. About 600,000 patients had to find new hospitals, and some of Las Vegas’ sickest children were sent out of state for treatment because specialized pediatric services provided by Sunrise were not duplicated in the region.
Less than a year later, Sierra merged with UnitedHealth Group Inc. The company cited the termination of the HCA contract as one of the contributing factors.
Sun reporter Marshall Allen contributed to this story.
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