The San Diego Union-Tribune by Paul Sisson –
November 13, 2013:
Health coverage is only as good as the doctors who accept it, an important truth for anyone buying a policy from Covered California, the state’s new medical marketplace.
The doctor networks supporting plans in the new health exchange, which is the main place for uninsured Californians to purchase subsidized policies, are getting more attention as residents compare and contrast offerings from different insurance companies.
While the policies listed on the new exchange each have a price clearly displayed, finding out which doctors are included can take a bit more digging.
In some cases, the doctor decision is straightforward. Big providers like Sharp HealthCare and Kaiser Permanente each offer their own plans backed by their own doctor networks.
In other cases, the connection between insurance companies and providers is not as obvious.
For example, Anthem Blue Cross and Blue Shield of California have worked their own deals with local providers to back the plans they offer in the exchange.
Blue Cross has partnered with UC San Diego as its top-tier provider, while Blue Shield has selected Scripps Health.
Executives with both health systems said they agreed to take less reimbursement from insurers in hopes that the exchange would deliver a robust volume of new patients.
Paul Viviano, chief executive of UC San Diego Health System, said he believes the university can work with Blue Cross to keep patient costs low.
“Lower cost was the focus of our conversation. We felt that we could develop a product that was useful and attractive,” Viviano said.
Likewise, Scripps CEO Chris Van Gorder said his organization decided that it was important to participate in the exchange even if it meant taking lower reimbursement than previously offered.
“I’d be surprised if anybody didn’t discount their rates,” he said. “We assume we are going to get volume in return, but we didn’t negotiate any guarantees. We just believed we had a community obligation to participate.”
Neither executive said how much his organization agreed to discount services in order to cement a deal with their exchange insurance provider.
These partnerships have created narrower lists of doctors participating in some plans than currently exist for individual policies that have been available from the same insurer in the past.
For example, there are about 2,233 doctors supporting Blue Shield of California’s health exchange offerings in San Diego County. That number represents only about 53 percent of Blue Shield’s total affiliated doctor network in the region, the insurer said in an email. And those who buy Blue Shield exchange policies will be able to use 12 of San Diego County’s 20 hospitals.
Anthem Blue Cross did not respond to a request for the number of local doctors included in the plans it sells in San Diego County, but a spokeswoman for UC San Diego Health System said all of its 820 local doctors are included.
The pattern, trading discounts for relationships that could deliver high volumes of patients, does not appear to be unique to San Diego County.
Eyeing more volume
Patrick Johnston, president and chief executive of the California Association of Health Plans, said insurance companies like Blue Cross and Blue Shield offered lower rates to providers as a way of helping deliver prices that are, on average, lower than those offered today in the individual health insurance market.
“Covered California insisted on health plans paring down costs so that consumers could afford the cost of health insurance,” Johnston said.
The executive said that, in many markets, insurers used volume to persuade well-known provider networks to take less in reimbursement than they were getting before.
“It is a common negotiating arrangement where hospitals can expect more patients and, in exchange, they have a rate that’s discounted,” Johnston said.
But the discount-for-volume strategy has not worked so well for smaller organizations, at least in San Diego County.
Wayne Knight, executive director of health care reform at Tri-City Medical Center in Oceanside, said many independent doctor groups balked when insurance companies started asking for discounts.
“A lot of the physician groups that are full, or close to full, they’re like, ‘We don’t need to do this,’ ” Knight said. “A lot of physicians are saying, ‘I’m not going to do it; it’s just not worth it.’ ”
Dr. Ted Mazer, an ear, nose and throat doctor and spokesman for the San Diego County Medical Society, said he did not participate in some Blue Cross plans due to reimbursement rates offered. He said many doctors who work in partnership with the larger health systems in the area do not realize that they have been signed up for exchange plans through their affiliation with that larger partner. Mazer predicted chaos in the provider world when patients start showing up, insurance card in hand.
“Most of the doctors don’t know what they’ve got, and they don’t know, really, if they’re in or out,” Mazer said.
He added that inaccuracies in Covered California’s online doctor directory also have persisted in some cases, despite attempts to make corrections.
Bulging patient demand
The big question, then, is whether the doctor networks assembled by insurance companies will be adequate to support demand. So far, local providers seem confident that their new patients will be able to get a doctor appointment with their newly purchased policy.
Johnston, the health plan association CEO, said he believes the networks will hold up.
“We expect that people are going to be very happy with the tailored networks set up in each region of California to provide care. Does that mean every doctor and hospital is included? No. The test should not be whether every provider is included but whether consumers have good care, reasonably available,” Johnston said.