Insurers limiting doctors, hospitals in health insurance market

The doctor can’t see you now. Insurers in California’s new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.

  •  To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state’s new health insurance market opening Oct. 1.

New data reveal the extent of those cuts in California, a crucial test bed for the federal healthcare law. These diminished medical networks are fueling growing concerns that many patients will still struggle to get care despite the nation’s biggest healthcare expansion in half a century.

  • Consumers could see long wait times, a scarcity of specialists and loss of a longtime doctor. “These narrow networks won’t work because they cut off access for patients,” said Dr. Richard Baker, executive director of the Urban Health Institute at Charles Drew University of Medicine and Science in Los Angeles. “We don’t want this to become a roadblock.”

To see the challenges awaiting some consumers, consider Woodland Hills-based insurer Health Net Inc. Across Southern California the company has the lowest rates, with monthly premiums as much as $100 cheaper than the closest competitor in some cases.

  • Health Net also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data.

In Los Angeles County, for instance, Health Net customers in the state exchange would be limited to 2,316 primary-care doctors and specialists. That’s less than a third of the doctors Health Net offers to workers on employer plans.

In San Diego, there are only 204 primary-care doctors to serve Health Net patients.

  • Other major insurers have pared their list of medical providers too, but not to Health Net’s degree. Statewide, Blue Shield of California says exchange customers will be restricted to about 50% of its regular physician network.

In response, California officials have been pressing Health Net and other insurers to add more doctors since companies filed their initial rosters in May. The state exchange, Covered California, says it will monitor enrollment closely once it begins next month and it’s prepared to step in if problems arise.

“Our interest is in assuring everyone enrolled in a plan has ready access to the clinicians they need,” said Peter Lee, executive director of Covered California. “That means if a plan can’t serve patients, we’ll close it down from taking new enrollment. That is in some ways the nuclear option.”

In recent months, the top priority for state officials and insurers has been affordable premiums. A smaller panel of doctors and hospitals generally yields lower rates because insurers can negotiate better discounts with providers who receive more patients.

  • The California Medical Assn., which represents more than 37,000 doctors statewide, thinks the state is underestimating the difficulties ahead. Based on its research, the organization is skeptical of the state’s claim that its health plans will cover about 80% of all California physicians. Other doctors worry about the effect on certain Latino and African American communities that have been historically underserved.

But some health policy experts say that medical costs will continue to escalate if patients can’t see their doctor regularly and get the follow-up care they need for chronic conditions such as diabetes. Similar concerns over patient access have surfaced in other states such as Maine and Wisconsin.

  • “We are nervous about these narrow networks,” said Donald Crane, chief executive of the California Assn. of Physician Groups. “It was all about price. But at what cost in terms of quality and access? Is this contrary to the purpose of the Affordable Care Act?”

The federal law requires exchange plans to include enough providers so that services are available “without unreasonable delay.” Likewise, state law sets various requirements for “network adequacy” so patients have enough doctors and hospitals nearby.

  • The differences in network size are noticeable across Southern California. Health Net has 920 physicians in Orange County, compared with more than 2,500 for Blue Shield, according to company data.

Health Net has fewer than 800 doctors in San Diego County, while nearly 3,000 physicians are available in an Anthem Blue Cross plan.

  • In addition to doctors, some big-name hospitals may be left out. A spokesman for Cedars-Sinai Medical Center said the hospital has received many calls from patients who were worried about keeping their access to the hospital and its affiliated doctors in the new health plans next year.

*Modified from a LATimes.com article

 

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