Sweeney calls for another hearing on OMNIA

A surprise Friday morning announcement from Senate President Stephen Sweeney calls for what would be the second joint Senate committee hearing to scrutinize Horizon Blue Cross Blue Shield of New Jersey’s OMNIA plan since its rollout two years ago.

“More than two years have passed since the Senate Health and Commerce committees held a joint hearing to examine the potential impact of the Horizon OMNIA insurance product. Horizon executives made numerous representations to the joint committee during the hearing,” Sweeney (D-West Deptford) said in a statement.

Sweeney’s record on Horizon has been mixed. He came out in support of Horizon during the contentious months that followed the September 2015 rollout of the plan, blocking efforts by Sen. Nia Gill (D-Montclair) to push bills that would create stricter regulations of tiered networks, but he also supported a $300 million raid of Horizon reserves in a legislative battle that shut down the state government over the summer.

“Today, I am announcing the Senate’s plan to hold another joint hearing of the Health and Commerce committees, where we will once again take testimony from Horizon’s leadership on OMNIA and other topics. At the joint hearing, we intend to carefully examine OMNIA’s impact on the marketplace as well as the impact of Horizon’s new narrow network Medicare Advantage plan,” Sweeney said Friday.

The newly rolled out Medicare Advantage plan is the subject of two more legal filings this year, one from the coalition of hospitals that have held on in a lawsuit against the state’s largest health insurer, and another from St. Peter’s Healthcare System. The plan, which has only been made available in some parts of the state, excludes those providers currently suing Horizon, among others.

Attorney Michael Furey said the October filings reserve the right to bring on another suit, and prevents the existing suit from being delayed.

“The claims are similar to the ones the hospitals have already made against Horizon in the pending OMNIA litigation,” he said. “To avoid delaying the trial in that case, scheduled for March 2018, the hospitals have asked the court for permission to file these claims at a later time in a separate suit.”

In a hearing for the Medicare Advantage filing on Nov. 8 in Bergen County Superior Court, Judge Robert Contillo commented on the broader implications of any ruling by his court.

“This is a fairly consequential, broad public impact matter,” he said. “It is heading toward the resolution by this court of certain core issues related to the longstanding OMNIA program. This new (Medicare Advantage) rollout is interesting. It does have certain apparent impacts on the (hospitals).”

Horizon is the newest entrant into the Medicare Advantage market, which is dominated by national players like UnitedHealthcare and Aetna, and includes a number of similarly tiered or narrow networks — which federal regulations from the Centers for Medicare and Medicaid Services allow.

The announcement from Sweeney on Friday comes at the tail end of Horizon CEO Robert Marino’s leadership. Marino is retiring at the end of the year, to be replaced by Chief Operating Officer Kevin Conlin — who played a significant role in the creation of the OMNIA network.

Sweeney said legislators have continued to receive complaints about the product from residents.

“Members of the Senate continue to receive frequent inquiries from constituents and health care providers concerning these products. New Jersey residents are continuing to have their choice of health-care provider limited,” Sweeney said.

Dr. John Poole, a Tier 1 surgeon affiliated with both Hackensack Meridian Health and Holy Name Medical Center, has experienced the issue firsthand.

If there is a patient in his office at Holy Name who is a member of Horizon’s OMNIA plan, he is likely to send them to Hackensack, since it will cost the patient less, he said.

And even though tiered and narrow networks aren’t new in the state, Poole said this network created as much controversy as it did when it rolled out because “it was sort of done in a black box.”

In other parts of the country, and previous iterations in the state, tiered networks relied on a buy-in of the concept from the providers, rather than the insurer making the decision of who gets to be Tier 1 and Tier 2.

“There is still anger over this (among doctors),” Poole said. “I’m at the epicenter of that. Horizon has such a big market share. There is anger over it because of the control they have.”

And that has created rifts among physicians.

“If I want to send patients to people I trust and work with and they are not in Tier 1 — and it has nothing to do with quality — that’s a problem,” he said. “It has created a rift.”

So, why haven’t more physicians been seen vocally protesting the plan?

“Doctors are so busy,” Poole said. “Some of it is just that they are not activists, and, deep down, they fear retribution if they are excluded from Horizon altogether, and what that would do for patients. Even though OMNIA is a minor product, Horizon is a major player.”

Sweeney said he is looking forward to examining Horizon next year.

“Our health care providers are continuing to be reimbursed less for the outstanding care they give, yet the premiums that insurance companies impose and the profits they make both continue to rise,” he said. “To be clear, these issues are complex, which is why a public hearing is necessary and appropriate. I look forward to a thoughtful and transparent hearing in the next legislative session.”

Tom Wilson, director of public affairs at Horizon, said, “As Washington continues to dismantle the Affordable Care Act, increasing uncertainty and raising the cost of insurance, Horizon is confident that the Legislature shares our priority of putting the needs of consumers, particularly seniors, first.”

New Jersey and tiers

In the past several years in New Jersey, there have been a number of tiered or narrow networks, in the State Health Benefits Plan, among Medicare Advantage plans and among consumer plans.

AmeriHealth New Jersey was the first to introduce tiered networks in 2013, followed by Horizon and Aetna — the latter at the request of the State Health Benefits Plan — in 2015.

Oscar Health had a tiered network in 2015 in New Jersey that was only offered in Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Ocean, Passaic and Union counties.

The new Medicare Advantage plan from Horizon launched this year offers a $0 premium for Tier 1 providers.

Aetna also has a $0 premium plan with Hackensack, Hunterdon Medical Center and Atlantic health systems that it introduced in 2014, a year before the OMINA plan was introduced and more than two years before Horizon introduced its latest plan.

AmeriHealth has a sort of alliance and narrow network with certain providers, offering AmeriHealth Advantage plans specific to AtlantiCare, Cape Regional Medical Center, Cooper University Healthcare, Deborah Heart and Lung Center, Hackensack Meridian Health and RWJBarnabas Health.

This summer, CentraState launched its own plan for employees, which has been a practice in the past among providers, with one of the OMNIA Alliance partners — Atlantic Health. The Community Care Network was created using QualCare, which also previously created narrow networks for hospitals.

Though Sweeney’s hearing is focused on Horizon’s impact, other insurers aren’t being singled out in the same way.

“The hearing is a revisiting of this issue by the committees and will focus on the impact of Horizon’s products on patients and providers as the largest insurer in the state. Other New Jersey insurance providers that offer tiered plans will also be invited to testify,” Sweeney told ROI-NJ on Friday.