Insurers limiting doctors, hospitals in health insurance market

[eridani]

http://www.latimes.com/business/la-fi-insure-doctor-networks-20130915,0,6433104,full.story

The doctor can't see you now.

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.

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.

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. That will make it a popular choice among some of the 1.4 million Californians expected to purchase coverage in the state exchange next year.

But 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.

Comment by Don McCanne of PNHP: These new data on use of narrow provider networks in state insurance exchanges, using Los Angeles County as an example, are important because they show us the extent to which this concept is being applied. Narrow provider networks reduce health care spending by limiting patient access to low cost providers - taking away choice - and by impairing access though supply-side contractions, that is, rationing care by limiting the supply of covered health care providers.

Another table accompanying the Los Angeles Times article (available at the link above) lists premiums for typical policies issued by these insurers for the benchmark silver plans. When comparing premiums with the numbers of physicians in the network, there are several interesting observations. Health Net, with the fewest number of physicians in their network, has the lowest premiums - no surprise. Blue Shield, California's nonprofit Blues plan, has premiums on the lower end though it has a much larger number of physicians than does for-profit Anthem Blue Cross, yet their premiums are similar. The nonprofit seems to be more concerned about patient access whereas the for-profit seems to be concerned more about profits. However, Anthem's EPO (exclusive provider organization) offers a larger choice in providers but extracts a much larger premium for that coverage. Comparing Anthem's two products, it looks like if you want an accessible doctor, you're going to have to pay for that right. Considering that Kaiser is a closed, integrated health system, it does have a fairly decent number of physicians, but it also has the highest premiums. It is likely that Kaiser's premiums are not high because of the number of physicians, but rather they are high to prevent destabilization of their business model by allowing too many new enrollees which might strain their capacity.

Health Net's silver plan premiums are set far enough below the others such that they will be very attractive for shoppers in the insurance exchange. The bronze plans have even lower premiums and will also be attractive. Most shoppers will be relatively healthy and will select their plans based on the premium - not on the physician networks nor on the out-of-pocket costs they would face if major health problems were to develop. Some of these people will become ill or suffer significant injuries. At that time they will discover that their choices of providers are too limited, that access may be impaired because the physicians are too busy or because they are too far away, and that the out-of-pocket expenses to which they are exposed will cause financial hardships.

Leave policy decisions to private insurers and they will always select policies that will advance their business models as opposed to policies that would provide optimal access, quality and affordability for patients. Having cheap premiums is no solution when you can't get a doctor when you need one, and, when you finally do, you're left broke.

Single payer would have avoided all of this, and it still can.

My comment: Underinsurance is why health care bankruptcies are STILL 50% of all bankruptcies sever years after reform.

[Ms. Toad]

1. A limited selection of doctors is part of any insurance plan.

Before making your decision to go with a particular plan, make sure your providers are on the list. Make sure the prescription drugs you take regularly are on the formulary. Make sure the pharmacy you use is in the network.

If you don't yet have a doctor, go through the list and find one and make sure s/he is accepting new patients.

This is standard fare - long before the ACA came along. And Kaiser? I've had more trouble with their network of doctors than with any other.

[SoCalDem]

2. Amen

We LOATHE Kaiser, but that was our only choice (aside from a PPO), so we had to give up the medical clinic we had used for THIRTY years..

Plans always come with limitations..

Only the rich have choice

[Ms. Toad]

4. I've been on Kaiser twice

The first time I never saw the same primary care doctor twice - their turnover was so high that by the time my next check-up rolled around the last doctor I'd selected for my PCP had left the practice. And the only competent GYN doc was not accepting new patients - so I had to go to a doctor whose approach was to tell me I couldn't possibly have PID since I wasn't sexually active. Problem with that theory: (1) I originally acquired PID was when I was not sexually active (2) he only inquired about intercourse - not a term my (same gender) wife and I use to describe our sexual activity. When I pointed that out to him, he asked how I was treated the previous time and prescribed the same medication again. End of story.

Second time around the doctors were fine, since we were permitted to choose a community based PCP (and use community based specialists). The administration was a nightmare (I spent 100s of hours correcting their claim processing errors), and when they decided to eliminate all community based providers (in a geographical area where Kaiser does not have a sufficient footprint to handle its customer base), my company switched to a different insurance company provider (and got us more comprehensive care, a much larger provider list, and better coverage for a lower premium).

[eridani]

6. Only in the US. In Canada, you can see any practitioner you want

This of course is limited by where you live--some people are a couple of hundred miles from the closest doctor, and whether s/he has any room in his/her practice.

[Ms. Toad]

7. I was specifically commenting on health insurance -

If I'm not mistaken, you have single payer health care in Canada rather than insurance.

[eridani]

8. Single payer is socialized insurance, not socialized health care.

Canadian practitioners are not employees of the government, and coverage is far more complete than is the case here. Too bad drug coverage is not included, though. People get private insurance or insurance through their employers for that.

[Ms. Toad]

9. That is really a different situation

when there is a single "insurance company" for an entire province. That creates a very different dynamic.

[eridani]

10. Indeed--one in which you can go to any doctor you want with room in his/her practice n/t

[Ms. Toad]

12. But it is different BECAUSE it is single payer system -

The implication in the article was that the limitation is something new which was a consequence of the ACA, when it is (and has been) the standard practice for any commercially available insurance plan.

[newblewtoo]

3. Here in NH

we are seeing a single provider (Anthem) who is limiting the hospitals available. So you are going to have hospitals for the poor and hospitals for the rich (which you pretty much have anyway). Oddly, I ran across a Canadian who was telling me he didn't use the government health facility because he had supplemental insurance through his employer which allowed him to avoid it and thus the 'wait'. First I had heard of that happening and I couldn't verify it as true beyond what this one person told me in a casual poolside conversation at a hotel while on vacation.

[leftstreet]

5. Status Quo ACA: Healthcare for the Rich, healthcare for the Poor

What a novel change!

[Nuclear Unicorn]

11. When pay-outs are lowered the only way to make up the difference is volume

IIRC -- That's how HMOs work. I don't fault the doctors, they need to get paid but with insurance companies in the mix they stand between the consumer and the producer.