ASHEVILLE — At long last, they're back in business together.

The new deal between Mission Health and Blue Cross Blue Shield of North Carolina is in effect as of Friday. Its announcement last week ended an icy six-month-long dispute that culminated in the contract's termination in October, potentially affecting about 260,000 people in Western North Carolina who are insured with Blue Cross.

The nearly two months with no contract left those insured with Blue Cross with fewer options to meet their health care needs. Without a deal in place, patients with Blue Cross would have to pay out-of-network rates at Mission facilities — with a few exceptions, such as emergency care — or to outright change their health care provider, of which the area's options are limited.

Now that they've struck a new accord, Blue Cross customers are again considered in-network at Mission.

In a statement Friday, Blue Cross NC spokesperson Austin Vevurka said the negotiation process with Mission, as with any provider partnership, is "to ensure our customers have access to high-quality, affordable health care."

"Generally speaking, most people would agree that we’re not getting what we pay for in health care," Vevurka said in an email to the Citizen Times. "The cost is too high, and value is too low. That is why it is so important for health care providers and health insurers to work together to find new and innovative ways to provide and pay for care.

"This is the only way we can slow the rise of health care costs and improve quality – and we are glad to once again have Mission Health as our partner in this important work."

Details of the contract have not been shared publicly. Both the insurer and the hospital system have cited confidentiality in refusing to share details, including the length of the new contract.

Mission declined to answer questions for this story, instead referring a reporter to a FAQ section on its website. There, Mission reiterates the start date of the deal and reaffirms that Blue Cross is again in-network as of Friday, among other answers.

Also in the FAQ section is a phone number for questions or financial assistance for patients on bills they received for care while Blue Cross was out-of-network. Mission declined to answer a question about whether or not it feels responsibility to bridge gaps with patients impacted after the contract expired.

'We're not really feeling the support'

The announcement was met with mixed reactions, with some area residents expressing relief while others felt the dispute damaged relationships with WNC communities.

There's people like Asheville resident Mary Ellen Gibbons, a nurse anesthetist and breast cancer patient, who fell out-of-network when the deal expired. Because she was no longer in Mission's network, she filled out a continuance of care form but said she was denied because she's not actively receiving chemotherapy.

Cancer is an expensive burden for most people. Gibbons said since she was diagnosed three years ago, she has spent at least $100,000 out of pocket. Even for blood work, she said falling out-of-network is a difference of several hundred dollars.

"It's absolute anger and frustration," she said. "We joke that cancer is the gift that keeps on giving. When you’ve already gone broke paying your in-network bill, and then to have to pay out of network, the well is already dry at that point."

Gibbons considers herself fairly lucky, given her circumstances. Her income and financial standing allows her some flexibility to take on the costs of cancer treatment.

She also had been monitoring a benign breast tumor from the time she was 18 until right around her 35th birthday. She had explored the possibility of a preventative mastectomy, no longer desiring to check on it with the same regularity. Her doctor told her the procedure was legitimate.

However, within three months, she went from completely healthy to a grade two, stage three breast cancer. The diagnosis, she said, was "terrifying."

During the time Blue Cross was out-of-network at Mission, she found out that she would not be covered by her insurance, an announcement of which she was not aware until she was in the middle of an appointment.

She said she left the facility "furious."

"Every appointment is scary," she said. "There’s a high stress level going in and then they say, 'Oh you’re going to pay out of pocket.' It’s like well, I’ve already tapped that resource."

The deal was a concern for many others, too. State Treasurer Dale Folwell, whose department directs the state employee health plan, said he had discussed the contract status with the presidents of Mission Health and Blue Cross Blue Shield NC. Blue Cross provides insurance through the plan, which has more than 700,000 members.

"Obviously we heard some concerns … about people having to choose different providers" during the period when Mission was out of network for people covered by the state plan, Folwell said.

"We’re very happy … that they’ve come to some agreement on this," he said Tuesday.

In comments that illustrate some of the economic pressures on both sides going forward, Folwell said he conveyed his concerns to Mission and Blue Cross leaders about the rising cost of care and his intention to getting people covered by the state plan more involved in efforts to limit them.

"We also have been very clear that the state health plan cannot be a part of the medical arms race going on this state," he said.

Folwell said he hopes the new agreement contains features designed to address those concerns, but that he knew little about its terms or how long it will run for. He said he would seek more information shortly.

"The details are very important here," Folwell said. He said they will impact people in Western North Carolina and provide clues as to what is likely to be in similar contracts between insurers and health systems over the state in the next couple of years.

For Gibbons, the dispute left her with a decision of where to continue her health care. Now two years out of chemo, she still receives treatment and regularly sees an oncologist. She has a date in mind — May 4, 2020 — where she would be considered in remission, merely a milestone, but not one that lends her much peace of mind.

She is critical of how Mission, in particular, handled the dispute, calling them "selfish." She said she's planning to continue her treatment at the Duke Cancer Center in Durham.

"We’re not really feeling the support right now," she said.

Some odds and ends

The start of the new agreement also happens to fall on the end of the open enrollment period for the Affordable Care Act.

The U.S. Centers for Medicare & Medicaid Services said 209,050 people in the state had signed up for ACA coverage for next year as of Dec. 2. However, statewide figures suggest the number of North Carolinians who get coverage through the ACA, often called Obamacare, may end up being lower in 2018 than it is now.

The Trump administration cut the enrollment period for the ACA in half, from about 14 weeks to a little more than six, and reduced the advertising budget for the program by 90 percent.

Jackie Kiger, managing attorney at Pisgah Legal Services, said Pisgah has seen "a steady demand" for assistance in the open enrollment period.

"There is some confusion whether the ACA is still the law," she said. "We’ve seen some national attention of repealing and replacing or repealing only. We have been reminding people and letting them know that ACA is still the law, financial assistance is still available and enrollment is happening."

North Carolina Gov. Roy Cooper called on the Trump administration to extend the open enrollment period. Cooper requested an extra week to allow people to enroll in the health insurance program for 2018. He has yet to receive a response as of Friday.

Back in WNC, the Mission-Blue Cross NC agreement put a damper on, but probably did not end, speculation that Mission was using its dispute with Blue Cross to promote a Mission unit that administers insurance plans for employers who are self-insured, meaning they pay for care themselves.

Mission Health President and CEO Dr. Ron Paulus dismissed that concern in an October interview. He says Mission does not offer commercial insurance and does not need to if existing insurance companies will adopt new models that offer incentives for providers to keep costs lower.

He said then that a Mission goal “is to find a way to share in the economic benefits from improved care” when negotiating agreements with insurers. He said he had repeatedly raised the issue with Blue Cross officials, who expressed little interest in alternative approaches.

But, Paulus’ remarks came before Mission and Blue Cross resumed contract talks.

Industry experts say many compensation arrangements in the health care industry pay caregivers more as they perform more procedures, not as they improve the health of their patients. Paulus said he wants to see more emphasis on the latter approach.

But he said that can be done in conjunction with insurance companies and cited Mission contracts with other insurers as evidence that Mission is not trying to push insurers out of the local market.

Insurer UnitedHealthcare was at the time “running billboards with the Mission logo. It’s not like we’re unwilling to cooperate with insurance companies. We’re doing that every day of the week,” Paulus said.