Young patients caught in conflict between MCG and Blue Cross Blue Shield




Gretchen Daly looked down the counter at Dairy Queen and spotted her 10-year-old son, Carter, getting ready to pop behind the counter and make Blizzards.

“You know it’s 100 grams for Blizzards,” she tells him.

“It’s 100?” Carter said incredulously as he reached for his insulin pump and sent out a big dose of insulin after snarfing down one of the frozen treats.

Even as they help in a fundraiser to benefit the Children’s Miracle Network and Medical College of Georgia Children’s Medical Center, the Daly family is facing the potential loss of the hospital and its doctors because of a contract dispute between the hospital and their insurer, Blue Cross Blue Shield of Georgia.

The hospital and its physician practice group have given notice to Blue Cross patients that it is terminating its contract with the insurer as of Aug. 15 because 10 months of negotiating a rate increase have gone nowhere.

The practice group, whose rate was last reset in 2003, said it would like a 13 percent increase, or about 1.4 percent per year over those nine years. It amounts to about $400 more per physician per year, said Dr. William Kanto, the chief medical officer for both the health system and the physician group.

“It’s not going to enhance very much the income of the physicians, but it will help us offset the cost of care,” he said. “And everyone I think realizes that the cost of care has gone up over nine years. And it is not fair to expect one group to accept that responsibility. And certainly the premiums have gone up significantly more” than 13 percent over nine years.”

MCG officials said Blue Cross has countered with a 3 percent offer it has refused to budge from; Blue Cross claims it has made several offers to try and reach an agreement.

Both sides say they are continuing to talk but accuse the other of not
responding to recent offers.

For the Daly family, it means facing an uncertain future. They moved back to the Augusta area from California in 2006 to be closer to family in McCormick, S.C., Gretchen Daly said.

“MCG was really one of the main reasons we moved to this area,” she said. “We were coming back to be closer to family, and I did a lot of research on where we could bring Carter where he would have the best care.”

Carter was diagnosed with type 1 diabetes at 20 months, and he sees MCG pediatric endocrinologist Chris Houk at least four times a year.

“My hope is that they can work things out and reach some sort of amicable agreement,” Gretchen Daly said. “It would be very hard to find another facility that will take care of Carter the way he is taken care of here.”

It would also mean losing extra services such as Camp Sweet Life for children with diabetes, which is run through the MCG program.

But Kanto, who was the chairman of the Department of Pediatrics at MCG for many years, said the physicians will work something
out, even without Blue Cross.

“We as a practice group are not going to abandon the patients,” he said. “We wish Blue Cross Blue Shield would address the issue of continuity of care as is required in the contracts. But we have been thwarted and frustrated by their inability or unwillingness to help us address this issue.”

In a statement issued Thursday, Blue Cross said patients in active treatment at MCG can seek to have that continue for a limited time at in-network rates.

Care that cannot be provided elsewhere might be covered longer but is determined on a case by case basis.

The MCG hospitals and health system are very close to reaching an agreement with Blue Cross, but because of the problem with the physician, rates will have to break with the insurer because otherwise there would be no one to see the patients, or it would create billing and benefit nightmares, Kanto said.

As far as funding from Blue Cross goes, perhaps it would have been better to be a shareholder than a physician in this case, he said.

“We would probably have done better if we took our money and invested it in their stock nine years ago,” Kanto said.

Standoff could cut off Blue Cross patients at MCG Hospital and Clinics