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Insurance plans could play a role in censuses at two hospitals

Insurance plans will likely decide whether a proposed second hospital in Janesville offers patients a true choice for in-patient services.

Earlier this month, Dean Health System and SSM Health Care of Wisconsin proposed a $140 million medical complex for Janesville’s southeast side that would include a 50-bed hospital.

In Janesville, Mercy Health System operates the 240-bed Mercy Hospital, which on average fills about 100 of its beds.

Just because Janesville could have two hospitals doesn’t necessarily mean every patient will have a choice to be admitted to one or the other. Some will and some won’t, depending in large part on their insurance plan and their willingness to reach into their own pockets to cover costs their plan won’t pay.

Joe Nemeth, Mercy’s chief financial officer, said choice in health care is determined at the insurance company and doctor selection level.

“Once you pick a doctor, a whole lot of things happen from that point on,” he said.

With the health care plans they offer workers, “employers make these choices on behalf of their employees, and this will not change with a new hospital,” Nemeth said.

Paul Pitas, Dean’s director of corporate communications, said that not all Rock County residents have a health insurance plan that requires the use of a certain hospital facility.

Still, the new hospital might not be an option for consumers who have restrictive health plans that don’t recognize Dean as a provider.

“When SSM Health Care of Wisconsin opens the new facility, it will be Dean’s in-network hospital facility in the Janesville market with all the benefits that entails,” Pitas said. “Anyone can choose to use the new hospital.”

If a health plan does not pay for coverage in the Dean network, the new hospital would be available to anyone who pays the difference between in- and out-of-network charges. It would also be available for anyone who wants to pay the full bill out of his or her own pocket.

Pitas said SSM has a discount policy for self-insured individuals, as well as a policy that addresses situations for patients who have insurance coverage that does not recognize nor pay SSM.

In proposing the new hospital, Dean and SSM said that 40 percent of patients in the Janesville area leave the area for care. While SSM cites Wisconsin Hospital Association for that figure, Nemeth said it’s “flat-out wrong.”

Nemeth said WHA data shows 27 percent of Rock County residents are hospitalized out of the county.

Either way, residents are leaving the county.

Pitas said Janesville-area patients with Dean Health Plan Insurance don’t have to go to Madison for hospital care and may opt for Mercy Hospital.

“Mercy is an in-network hospital facility under Dean Health Plan,” he said. “A significant number of those patients will be able to receive care at the new hospital.”

Nemeth said the addition of the new hospital would reduce the in-patient population at Mercy Hospital, which isn’t filling the hospital beds it has now.

Most physicians in Rock County have admitting privileges at the hospitals in Janesville, Beloit and Edgerton, he said, adding that with the new hospital, Dean may not allow its physicians to admit to Mercy Hospital.

“DeanCare insurance will almost certainly direct that its insured patients receive care at the new hospital,” Nemeth said. “Thus, patients receiving care by Dean physicians will be denied choice by DeanCare insurance to only receive services at the St. Mary’s Hospital.”