ASHEVILLE – Anyone who has cable or satellite television knows the drill.

A group of TV stations and a TV provider can't agree on a contract, so each takes their case to the public with claims the other side is demanding unreasonable terms.

Usually, a deal gets done a few days before or after deadline and consumers are left with little feel for who was right and what eventually settled the dispute.

Blue Cross Blue Shield of North Carolina and Mission Health are engaged in a similar debate now, some experts say, as both go public in pursuit of the upper hand ahead of an Oct. 5 deadline.

The difference is in what's at stake. Instead of having trouble watching "The Blacklist" or "Modern Family," thousands of Western North Carolina residents face not knowing what their insurance will cover for a visit to their family physician or where they can have a surgical procedure done.

Blue Cross NC has around 70 percent of the state's private health insurance market, insuring about 3.5 million people in the state. In 16 WNC counties, about 260,000 people have Blue Cross NC health insurance.

Without an agreement with Mission, many of the insurer’s customers could find themselves searching for new doctors – or even driving out of state for care.

Mission gave Blue Cross NC notice July 5 that it was terminating its contract with the insurer, effective in three months.

Mission says Blue Cross NC was unwilling to offer a reasonable new contract during months of negotiations and if it did not act, the terms of its existing contract mean it would be stuck with no rate increase in perpetuity.

Blue Cross NC says it is time to halt or at least slow rate increases and that it will not negotiate with Mission until the health system withdraws its notice of termination.

Mission's CEO says nothing less than the survival of WNC's largest private employer is on the line.

Blue Cross NC says the dispute’s outcome will have a major impact on how much employers and individuals in the region pay for health insurance.

For WNC, the argument is a proverbial clash of titans. Mission is far and away the region's largest health care provider and Blue Cross NC covers more than a quarter million WNC residents.

With two hospitals in Asheville, five more in smaller towns across WNC and ownership of numerous physician practices and other health care providers, Mission employs more than 12,000 people.

No wonder several Buncombe County commissioners were exasperated to learn at a commissioners' meeting Tuesday that the two sides are not even talking.

"You guys need to get together and figure this out. This is not acceptable," Commissioner Joe Belcher told Blue Cross NC and Mission representatives.

Contingency plans

If the two sides can't agree, people who have Blue Cross NC insurance and get their care from a Mission health care provider would face a difficult choice. They could either find a new health care provider to maximize the amount Blue Cross NC pays for their care, or make no change and pay more out of pocket.

Visits to emergency rooms at Mission hospitals in Asheville, Brevard, Franklin, Highlands, Marion and Spruce Pine would still be reimbursed at Blue Cross's higher, "in network" rates.

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But most people with Blue Cross NC needing nonemergency surgery, for instance, would have to go to other hospitals or shoulder more of the cost themselves.

Changes in other services would also be affected. Mission employs more than 500 physicians and includes one of the region's largest providers of home health care services, CarePartners.

There would be some exceptions to maintain continuity of care with the same provider for ongoing conditions, Blue Cross NC says.

Blue Cross NC says it and other hospitals in the region are gearing up to help people switch to providers outside Mission Health.

Other hospitals "are prepared to handle these changes," Blue Cross NC spokesman Lew Borman said. "We do have other health systems in network with high quality and lower rates."

Spokeswomen at Haywood Regional Medical Center in Clyde and Park Ridge Health in Fletcher said their hospitals and affiliated doctors have capacity to handle patients who might otherwise have gotten care from the Mission Health system.

Park Ridge, for instance, has set up a special telephone line to help people find a physician or other caregiver in its network. It has providers in more than 30 offices in Buncombe and Henderson counties.

"We want our friends and neighbors across Western North Carolina to know they can count on us to be there for them when they need care from an in-network health care system," said Jim Bunch, Park Ridge president and CEO.

It is difficult to say, however, whether there is enough capacity in the WNC health care system to take care of all people with Blue Cross NC insurance without using Mission Health facilities and providers.

The number of physicians directly employed by Mission appears to be greater than for Haywood and Park Ridge combined. Of course, many physicians work for independent practices or other hospitals in the region.

There are likely a number of services or medical procedures for which Mission is the only provider in the region.

Those may include some types of specialty pediatric care, certain heart procedures, "high-level trauma and neonatal intensive care," said Rowena Buffett-Timms, senior vice president of government and community relations at Mission Health.

Patients in WNC will see a significant disruption if Blue Cross NC and Mission do not work out an agreement before Oct. 5 and some patients might even go to South Carolina or Tennessee for care, said Casey Hite, CEO of local medical equipment supplier Aeroflow.

"We believe that these people will be able to find alternate care, as local physicians and practices are cooperating, but this could impact so many people -- many of them would probably be willing to travel to seek more affordable care," he said.

Belcher said Tuesday it will be hard for many people to even conceive of the idea that they must pay more to get care at a Mission facility for any procedure, rare or routine.

A local resident will "come into Mission Hospital, walk in there, and somebody's going to tell them they're out of network? ... They're going to go, 'What?' " he said.

The bottom line

Even though both institutions are nonprofits, the sticking point between Blue Cross NC and Mission is the same as in most difficult contract negotiations: Money.

How much is unknown. Neither side has discussed the amount of money at stake or said anything specific about how far apart the two sides are.

Mission has said the payments it would get under the multi-year contract Blue Cross NC proposes would essentially be the same as they are now.

Patrick Brady, director of major and national accounts for Blue Cross NC, told Buncombe commissioners Tuesday that the insurer wants a one-year "pause" in rate increases.

"Our customers cannot agree to unreasonable cost increases year after year," he said.

He said Blue Cross NC wants its reimbursements to Mission "tied to quality and outcomes" of patient care and said rate increases could come in later years of a new contract with Mission.

Mission says its agreement with Blue Cross NC limits how much it can say about how large an increase it wants.

It appears many of Mission's costs are rising at rates in the mid- to upper single digits.

President and CEO Dr. Ron Paulus noted in a July 5 interview a consulting firm's projections that medical costs nationwide will rise 6 percent this year and 6.5 percent in 2018.

Paulus said drug companies are raising the amounts they charge Mission by more than 10 percent and medical device makers' prices are going up 5 to 10 percent.

Brady used a hypothetical figure of a 6 percent rate increase in charges by Mission when talking to Buncombe commissioners about how paying Mission more would add to the cost of insurance.

Paulus and Jill Hoggard-Green, chief operating officer at Mission Health, both said they would be happy to have a contract in which there would be significant rewards for Mission for the success of medical treatments.

"We welcome pay for performance, but we must have an inflationary increase, a small inflationary increase," Hoggard-Green said.

Paulus noted that Mission has been named one of the nation's top 15 health systems by Truven Health Analytics five of the last six years. He said Mission officials have encouraged Blue Cross NC to more closely tie payment to patient outcomes.

Mission's record of improving care suggests that would be to its benefit, he said.

"We've been performing and we don't get anything for it," Paulus said.

Special circumstances

Hospitals across the country rely on making money from their charges to health insurance companies to make up for the fact that they generally only break even or lose money on procedures paid for Medicare and Medicaid.

The economic model in the health care industry is "odd," said Chris Kane, an industry consultant with Nashville, Tennessee-based, Progressive Healthcare, because "commercial insured patients are the source of all of the profit margin."

That puts special pressure on negotiations between hospitals like Mission and insurers like Blue Cross NC, he said, because hospitals have few other options to bring in more revenue.

"It's easier to pursue a disagreement with an insurance company than it is to send an email to President Trump" seeking higher reimbursement rates for government programs.

Mission says the percentage of its patients whose care is covered by commercial insurance is lower than for most hospitals because so many people in WNC are on Medicare, which covers those 65 and older, and Medicaid.

Medicaid covers low-income pregnant women and children, plus disabled people and the elderly below certain income guidelines, such as nursing home residents who have exhausted their savings.

Recent figures show only 23 percent of Mission hospital patients had commercial insurance compared to 35 percent for Charlotte-based Carolinas Healthcare System, Mission says. Mission said 49 percent of its patients were on Medicare and 21 percent had Medicaid.

Paulus said Mission has cut its operating costs because of the economic pressure that comes with having so much care paid for by the federal government, but its patient mix means it must get an increase in payments from Blue Cross NC.

"No health system could survive what we're being asked to do (by Blue Cross NC) if they have the demographics that we do and they already perform like we do," he said.

Further complicating the Blue Cross-Mission dispute are the timing of the impasse, uncertainty in the health care industry created by the possibility that the federal government will dramatically rewrite the Affordable Care Act and, possibly, an initiative by Mission that could put it in competition with Blue Cross NC.

"The constituency that's critical in all this are the employers who are the customers of Blue Cross locally," said Kane, the health care consultant. With the insurance enrollment period at many companies looming in the fall, many employers are making decisions now and over the next few weeks on what insurance their companies will offer workers, he said.

That puts pressure on Blue Cross NC to come to an agreement with Mission Health. Mission announced Monday that it had signed a multi-year contract with insurer Cigna to provide in-network care to those Cigna insures.

Blue Cross NC lost more than $400 million over three years because claims for care via ACA plans were higher than expected, Borman said.

Mission in recent months launched a unit called Healthy State that offers services that could provide an alternative to Blue Cross NC.

Its website says it "offers group health plans, provider networks and benefit program management services to help employers lower their health care costs and improve the health and productivity of their employees."

Buffett-Timms said Healthy State is a "employee health benefits provider" that serves employers that are self-employed. It uses a network of physicians and hospitals that includes Mission facilities and others.

Blue Cross NC also administers plans for employers that are self-employed.

Buffett-Timms said "just a few" employers have signed on since Healthy State began about a year ago and that it "is not a competitor in the individual or small group insured market."

Neither side answered questions on whether Healthy State is a factor in the impasse.

High, low or in-between?

A key question in negotiations is whether Mission is charging too much for care today. Blue Cross NC says it is. Mission disagrees.

Some figures on the cost of treatment at Mission are publicly available, but those cited by Blue Cross NC and Mission are contradictory.

Blue Cross NC said recently that Mission's costs for several common procedures were significantly higher than those at comparable hospitals, as reflected in claims submitted to Blue Cross NC. It pointed to figures in an online tool the insurer offers to allow people to compare the cost of care at different providers.

Julie Henry, a spokeswoman for the N.C. Hospital Association, said Blue Cross NC's cost estimator is "not really very helpful" for the average consumer because the complexity and severity of patient conditions at one hospital can vary radically from those treated at another.

"It's not really apples to apples," she said.

Blue Cross spokesman Lew Borman said the figures are comparable because they are adjusted for high-risk cases.

The online tool "has been touted nationally as one of the first in the nation to offer transparency to hundreds of non-emergency procedures," he said.

Buffett-Timms said data maintained by the N.C. Department of Health and Human Services show Mission charges are 23 percent less than the average for similar hospitals and 7 percent below the average of other hospitals in WNC.

Blue Cross NC, she said, "has refused to share its data with Mission. ... We have found no correlation between their data and our actual experience of reimbursement from BCBSNC."

She said the secrecy shows Blue Cross NC "is not constrained by the truth, nor willing to be transparent with its own data."

There is also the question of whether Blue Cross NC is practicing what it is preaching.

Brady, the Blue Cross executive, told Buncombe commissioners 40-some other hospitals in the state have been willing to accept the same pause in rate increases the insurer wants from Mission.

But Mission says Blue Cross NC is still asking employers and individuals who buy insurance from it to pay more. The insurer had asked for increases that average more than 14 percent in public filings so far this year, Mission said July 5.

Borman said he is uncertain where that 14 percent figure comes from.

Rate increases for group policies Blue Cross NC has filed with regulators this year "were generally in the mid-single digits," he said.

Borman said Blue Cross NC has asked for about a 24 percent rate increase for individual insurance offered through the federal Affordable Care Act, largely because of uncertainty over what the federal government will pay through the ACA.

Talking or not?

Mission accuses Blue Cross of NC of "a pattern of acting aggressively against health care providers who give notice of termination in order to intimidate them."

Blue Cross NC says it stops negotiations once a provider gives notice of termination of a contract because to do otherwise would confuse consumers and delay their moves to find other caregivers. It says it will be happy to talk to Mission once the health system withdraws its notice of termination.

Regardless of who is to blame, both sides say negotiations are at a standstill.

People in the industry say talks between insurers and health systems often hit snags.

Most are resolved before a dispute becomes public, but it is not unusual for a spat to get media coverage. Sometimes the parties do not come to an agreement before the old one expires.

Both sides in the Blue Cross NC/Mission Health dispute have cranked up publicity efforts in hopes of persuading the public to back its position.

"This is about hearts and minds and wallets, and so you see these public relations activities in order to convey ... which side has the better argument," Kane said.

Henry, the N.C. Hospital Association spokeswoman, said parties are usually able to come to an agreement before the deadline.

That's what both Kane and Hite, the Aeroflow official, expect to happen in this case.

Mission is too important to Blue Cross NC and Blue Cross NC is too important to Mission for the parties not to try hard to work out a contract, Kane said.

However, Hite predicted some worries for WNC residents until that happens.

"In the meantime, it's unfortunate to see these negotiations play out in a public space, creating so much uncertainty for people who rely on steady support and care from Mission Health," he said.

More information

Parties involved in the Blue Cross NC/Mission Health dispute have set up websites and other means to get their side of the story to the public and to help people make alternative arrangements to get care.

--Information from Blue Cross NC is available via www.bcbsnc.com/missionhealth or by calling 1-800-446-8053. Those insured by Blue Cross NC can also call the number on the back of their insurance card.

--Mission has set up a website with information on the dispute, www.standwithmission.org, and a telephone number people can call with questions: (828)417-0480.

--Fletcher-based Park Ridge Health offers help locating providers in its network at 1-855-774-5433.