Maron leads a contingent of hospitals that have been classified as Tier 2 facilities under Horizon Blue Cross Blue Shield's new OMNIA plans.
Michael Maron is a man on a mission.
The president and CEO of Holy Name Medical Center in Teaneck is personally leading the charge in the fight against new health insurance plans rolled out by the state's largest insurer, Horizon Blue Cross Blue Shield of New Jersey.
Maron leads a contingent of hospitals that have been classified as Tier 2 facilities under Horizon Blue Cross Blue Shield's new OMNIA plans, rather than preferred Tier 1 hospitals, where patients have lower out-of-pocket costs.
While only three of Hudson County's six hospitals are currently in-network with Horizon, Maron is bringing his case before Hudson County residents, who make up a portion of his hospital's patients.
Among Maron's biggest charges are that the selection process for Tier 1 was not done in what he would call a transparent manner, that OMNIA plans were designed to "shift business" to Tier 1 facilities, and, that the marketing campaign for new plans damages the reputation of his and other Tier 2 hospitals.
"The general public perceives Tier 2 as being lesser quality," Maron said in a recent meeting with the Jersey Journal's editorial board. "They're perpetuating this myth that there is this valid criteria that we failed to meet, and so people believe that because of their size.
"I could be an Aetna patient, I could be a direct Medicare patient and I'm going to second-guess should I go to Holy Name for my care because they weren't good enough for Blue Cross - which just isn't true.''
Holy Name Medical Center in Teaneck has been designated a Tier 2 hospital under Horizon's OMNIA plans. CRITERIA IS KEY
Horizon, which insures 3.8 million people in New Jersey, developed OMNIA's tier system using six criteria, categories that range from "clinical quality" to "commitment to value-based care." The insurance company contends that tiered plans are nothing new and that OMNIA will help reduce costs for its customers.
Along with the new plans, Horizon also established its OMNIA Alliance, a collaboration with some of the "top health care organizations" in the state to develop new ways of keeping individuals healthy and lowering health care costs.
While some of the state's largest healthcare systems -- including Hackensack University Medical Network, Atlantic Health System and Barnabas Health, among others -- make up the OMNIA Health Alliance and are therefore designated as Tier 1, Holy Name and many of the state's other Catholic hospitals were given the Tier 2 distinction.
"What we've objected to all along on this, and continue to object to, is the manner in which this was rolled out and done," Maron said. "There was no transparency, no communication as to the formation of this network and alliance. It was all done under a veil of secrecy."
Thomas Vincz, a spokesman for the insurance giant, said the company provided the public an in-depth look at its tier criteria this fall - several months before the plans became available on Jan. 1.
"Tiers are common among insurance carriers in New Jersey and across the country, and Horizon has been more transparent about the criteria that made up our OMNIA Health Alliance than any health insurance company," said Vincz, who provided The Jersey Journal with a breakdown of the criteria.
"We provided the OMNIA Alliance criteria to the Legislature and publicly on October 5. When Horizon decided to develop new, lower premium health plans, we used the Alliance partners as the basis of OMNIA Tier 1," Vincz added.
But Maron maintains that he was never shown his own hospital's score, let alone how the other hospitals fared against each metric.
He specifically pointed to "commitment to value-based care" as one such category he believes Holy Name wasn't judged accurately. The Teaneck hospital was one of six medical institutions in the state to participate in Horizon's Accountable Care Organization - an experimental program that sought to manage a pool of patients' care for 12 months for less than a pre-determined benchmark.
Michael Maron, president and CEO of Holy Name Medical Center, is leading the charge against Horizon's new OMNIA insurance plans. Maron said Holy Name was the only ACO hospital that performed well enough in 2014 to receive a bonus from Horizon. Three of the facilities, including his own, were later designated as Tier 2 hospitals under OMNIA, while the other three were given Tier 1 status.
"Yes they have circulated this list," Maron said of the criteria, "but actions and subjective interpretation belie most of these criteria."
OMNIA's five plan offerings range from the Bronze plan - which includes the lowest monthly premium but highest out-of-pocket costs - to a Platinum plan that features the highest monthly premium but pays, on average, 90 percent of covered medical expenses. Members can seek care at either Tier 1 or Tier 2 facilities but will have lower co-pays and deductibles at Tier 1 hospitals and with Tier 1 doctors.
Meanwhile, Maron also alleges Horizon negotiated separately with the larger systems whose hospitals comprise the OMNIA Alliance and a bulk of the Tier 1 list. He says Horizon developed the two-tiered format to "shift business" to those larger systems by offering lower co-pays and deductibles.
"What it appears happened was they signed exclusive arrangements with the largest systems in the state - the most expensive systems in the state. But it also happens to be where their largest book of business goes," Maron said.
But Vincz says outside the OMNIA Alliance hospitals, additional Tier 1 facilities were identified based on locations that were "not already covered by OMNIA Health Alliance partners, breadth of services, and market preference."
"The OMNIA Alliance and the tiered network of OMNIA products were carefully crafted in compliance with all regulations and laws applying to our business," Vincz added.
MOVING FORWARD
The Medical Society of New Jersey, meanwhile, is also concerned, its CEO Larry Downs said. The organization, which represents more than 8,500 doctors in the state, is currently asking Tier 2-designated doctors to fill out a survey on what effect they perceive it to have.
As for Holy Name, the hospital maintains a daily population of 300 patients on average and had 3,000 employees.
Fifty percent of the hospital's patients are Medicare patients, while 15 percent are on Medicaid, Maron said. Five percent, he said, are indigent.
The remaining 30 percent of patients use commercial carriers, with Horizon being the most used insurer for this subset of patients, Maron said.
While three Hudson County hospitals -- Palisade Medical Center, Meadowlands Hospital Medical Center and CarePoint Health Christ Hospital -- remain out-of-network with Horizon, Jersey City Medical Center is designated as a Tier 1 hospital.
"Jersey City Medical Center-Barnabas Health is a not-for-profit hospital which maintains a fine working relationship with Horizon Blue Cross Blue Shield as an in-network provider with an excellent reputation for providing the highest quality care with outstanding outcomes," JCMC spokesman Mark Rabson said.
Bayonne Medical Center and Hoboken University Medical Center -- both CarePoint Health hospitals -- are in-network with Horizon until May 1 and June 1, respectively. Negotiations between Horizon and the two facilities are ongoing, CarePoint Health spokesman Jarrod Bernstein said.
Meanwhile, the Tier 2 hospitals have taken their fight to court, filing several lawsuits against the insurer, including one that seeks to block the advertising of the OMNIA plans. Beyond the litigation, Maron wants to see revised legislation and additional regulation to curtail OMNIA and other plans like it in the future.
"We did not want to be put into this position,'' Maron said. "They (Horizon) are the largest payer. We've always had a good relationship with them. They just got this one wrong."
Editor's note: This article has been updated to reflect that Bayonne Medical Center and Hoboken University Medical Center remain in-network with Horizon until May 1 and June 1, respectively.