Shelley Toreson, who lives near Reno, Nev., had health insurance for years — but not anymore. Instead, she is part of an unusual Nevada nonprofit that helps connect 12,000 uninsured residents to doctors and hospitals that are willing to accept a lower, negotiated fee for their services.
"The cost just kept going up and the coverage kept getting less," Toreson says, explaining her frustration with her old insurance.
So instead, the 62-year-old signed up with the Access to Healthcare Network, a medical discount plan that helps uninsured residents with low and moderate incomes get care from 2,000 providers around the state. In addition to the provider charges, members also pay $35 a month to the network. That fee buys them ongoing help in finding providers and navigating complicated medical bills.
One in five people in Nevada is uninsured.
Toreson says that now that she has signed on with Access to Healthcare, she knows the cost of a mammogram or other procedure upfront, so the charges for her medical care no longer catch her off guard.
She recently needed gallbladder surgery, for example, and because she knew the cost, was able to borrow about $1,700 from family and friends to pay for it. She had to wait about three weeks to get the surgery, she says. But a network care coordinator helped her work out the details.
"They're so willing to work with you on whatever kind of problem you might have," Toreson says. That wasn't her experience with traditional insurers, she says, where the underlying attitude often seemed to be, "How are we going to not pay this?"
Based in Reno, Access to Healthcare is the brainchild of Sherri Rice, who has worked for 25 years as a consultant to various nonprofit organizations.
Health care and government groups in Reno came to Rice for help in figuring out a way to get care for the uninsured. She says she told them that the key stakeholders — including doctors, hospitals, government officials and financiers, as well as patients — would need to take some responsibility to make the discount plan work.
"I started by asking the hospitals for the [discounted] rates," recalls Rice, who now serves as the network's CEO. "I asked the uninsured to pay cash at the time of service plus a membership fee. I asked the providers to lower their rates. I asked the government to put money in to help sustain the network. I asked everyone to do something."
Rice calls Access to Healthcare a "shared-responsibility model" because the patient and the provider each contribute, and neither is overburdened.
"Our rules are very strict for our members," she says. There's a swift and straightforward penalty for any member who doesn't pay a medical bill, or who is a no-show at a medical appointment more than once without calling to cancel. "I kick them out of this network," Rice says, "and they can't ever come back."
She says about two-thirds of the members are employed but have a job that doesn't include health benefits.
Helen Lidholm, the CEO of St. Mary's Regional Medical Center in Reno, where Toreson had her gallbladder surgery, says her hospital is happy to take network patients. "This is an organization that is taking the poor, many of them disenfranchised, and giving them an opportunity to participate in such an important aspect of life — [their] own health care," Lidholm says.
But, she adds, the model works only because her hospital gets higher payments for other patients from private and public insurers. And even with those payments, Lidholm says her hospital loses money on discounted surgeries like Toreson's.
"It's a good deal," she says. "Could we afford to do that for everyone that walks through the door? No."
The negotiated fees that network members are charged must be paid upfront and can add up — particularly for people with chronic or expensive conditions like cancer. Some network members have to raise money through bake sales or other charity events to pay their bills.
Still, Lidholm says giving care to the uninsured before a health problem escalates into an emergency winds up saving everyone the higher cost of urgent care. And the network's coordinators do a good job, she says, of helping their members stay out of urgent situations.
"Access to Healthcare Network has the lowest emergency room utilization of any payer that I work with," Lidholm says. "And that's remarkable."
Starting next year, two-thirds of the Access to Healthcare members will probably gain traditional insurance coverage because the new federal health law requires them to have it. Some members will be eligible for federal subsidies to help them pay for it, Rice says, and the network is partnering with St. Mary's Health Plans to offer them policies that comply with the Affordable Care Act.
But Rice says the network will continue because there will still be people who fall through the cracks — including immigrants who are not in the country legally, and people who, for whatever reason, decide not to buy health insurance and make too little money to be subject to the federal mandate that requires it.
This story is part of a reporting partnership that includes Capital Public Radio, NPR and Kaiser Health News.