WE HAVE ALL been hearing and reading about the new Horizon Blue Cross OMNIA Alliance Insurance product, but no one — not the consumers, not us as legislators, not the doctors or hospitals who provide our care — truly know what impact this product will have on us all. The recent joint hearing of the state Senate Health and Commerce Committees held on Oct. 5 unfortunately did not provide answers to the public at large.

Based upon my own experiences in the health care arena recently due to my personal illness, I have grave concerns regarding the lack of transparency surrounding the criteria and methods by which hospitals were chosen. I agree with comments made by senators during the hearing that characterized the creation of OMNIA as having "the earmarks of being a potential monopoly, as well as serious consumer protection issues." That the processes used by Horizon to create OMNIA, and the New Jersey Department of Banking and Insurance to approve it, need scrutiny, transparency and oversight is an understatement.

The residents of New Jersey may not be aware that Horizon's footprint in this state is enormous, with 3.8 million residents as customers — almost 43 percent of New Jersey's 8.9 million residents. No other non-government insurer comes close. Such clout is a powerful tool that can drive up prices while monopolizing markets. It is for these reasons that we have to be certain that proper oversight and consideration has been given to this approval process.

In particular, DOBI is tasked to regulate insurance in a manner that "protects and educates consumers" partly by reviewing insurance products and rates for compliance with regulations. If a product is not in compliance, approval is to be withheld. In this instance I have concerns that approval was granted, even though DOBI admitted that it knew that certain required network adequacy measures were not met. As a result, access to all of the state's trauma centers is not ensured, nor is access to hospitals with obstetrical services in certain counties.

Access differs

The term "access" has been tossed around with different meanings according to each speaker. To Horizon, access means only that care can be obtained, apparently ignoring differences in consumer cost and choice. To the consumer, access means the ability to select the health care provider that meets his or her particular needs without being penalized financially. Higher cost restricts access; this seems to be at the core of OMNIA's design.

I have grave concerns that Horizon's "tiering" system adds a substantial layer of out-of-pocket cost if the consumer's choice has been relegated to "tier 2" status. Moreover, we still don't even know how hospitals were sorted into the two tiers. The most forthcoming fact to date came from Horizon executive Kevin Conlin, who stated that 25 percent of the sorting was "discretionary." This is not comforting, and not supportive of consumer protection. DOBI needs to step in.

That's why 17 hospitals have chosen to sue DOBI in a case brought by a former DOBI Insurance Commissioner who makes the reasonable argument that the approval process must be redone to be more thorough and allow for public hearings. I agree.

I cannot avoid looking at the hospitals in my own county, wondering why each was assigned its particular tier. While I am pleased that Hackensack University Medical Center made the cut in the "tiering" system, I am baffled that Holy Name and Valley were accorded tier 2 labeling, particularly as the Centers for Medicare and Medicaid Services previously saw fit in Bergen to reward these two hospitals for having provided value — value measured by a set of criteria, consistent and transparent nationally.

Holy Name and Valley are also magnet hospitals, indicating the highest recognition of nursing excellence, awarded to only 6 percent of U.S. hospitals. Fewer than half of OMNIA's hospitals achieved this distinction. Perhaps most baffling was Holy Name's performance in Horizon's accountable care organization, which included three Alliance hospitals and two other "tier 2" hospitals. Holy Name was the sole participant to be awarded bonus payments based on Horizon's own criteria, i.e., out-performing the Alliance hospitals. Tier 2? Something is amiss.

Formidable purchasing power

Horizon's formidable buying power in the state should not be a free pass to create new law. I have significant questions regarding what appears to be a flawed process of oversight in the creation and approval of OMNIA, and I am concerned that economic disruption will occur statewide as Horizon subscribers are funneled away from their current hospitals and doctors to lessen their out-of-pocket costs. As an initial step, I would ask DOBI to perform a complete and transparent review of OMNIA. It's time we all started looking out for the consumer first.