Some reading about the challenges that surface when exchange plans eliminate specialty hospitals (e.g. the local Children’s hospital) and thus disrupt care for chronically ill patients reminded me of a recent project at our house.

My wife bought an old, beat up armoire for $1 (really) that she was going to restore for our youngest daughter’s room. It obviously needed a coat of paint and there was one drawer rail that I had to reattach. It turns out that the board to which the drawer rail was to attach was missing. No worries. I would simply add another board as this was in the back and not visible. In the process of attaching that, the front board came loose as well, the old staples simply gave way. That meant that I would have to somehow rig a hidden block to hold up the front board without interfering with the opening and closing of the drawer. Lo and behold, the other side had the same issue, so that little fix would have to be duplicated. The paint job and a couple of nails turned into the entire piece of furniture disassembled in our entry way for several days. You know the story.

Back to our little narrow network problem.

So specialty hospitals, especially children’s hospitals but also certain other facilities focused on specific diseases, are often more expensive on a per unit basis. A $23,000 appendectomy at the specialty place can be done for $14,000 at the low cost community hospital. It seems logical in light of the objective of reformers to set up a system that moves patients over to get the $9,000 savings. Of course, the specialty hospital gets excluded from the network.

Which is great, except for those chronically ill patients, who happen to need coordinated care the most and are also big drivers of cost, who now have their long term care disrupted because their hospital and physicians are not in their new network.

That is not good, so the feds begin to tinker. Let’s offer a longer term transition period. Let’s say that if the network does not provide essential services, then the exchange product must pay for those out of network services. Yes, that will blow up the economics of the insurance, but we’ll figure that out later. And yes, then we’ll start arguing over whether or not the service is actually provided, but we’ll figure that out later, too. And yes, yes, that means the patient is now getting some of their care through the contracted network and some outside of it, and yes, yes, that is hardly the goal of accountable care, but we’ll go to the hardware store and get some tape and glue and baling wire and fix that, too.

Soon, the thing will be disassembled in our collective front hallway.