Tuesday, November 19, 2013

Doctor Networks Supporting ACA Compliant Plans

Health coverage is only as good as the doctors who accept it, an important truth when buying a policy from Covered California, the state’s new medical marketplace or an insurance carrier directly.

The doctor networks supporting plans in CoveredCa (new health exchange) which is the place for uninsured Californians to purchase subsidized policies, as well as carriers directly are getting more attention as individuals compare and consider 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. 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.

Carriers like Anthem Blue Cross, Blue Shield of California and HealthNet have worked their own deals with local doctor and hospital providers to back the plans they offer on and off the exchange. Anthem has partnered with UC San Diego as its top-tier provider, while Blue Shield has selected Scripps Health.

Executives with in each health care system say they agreed to take less reimbursement dollars from insurers in hopes that the exchange would deliver a healthy new volume of 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 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 would disclose how much their organizations agreed to discount services in order to cement a deal with their exchange insurance provider.

These partnerships have created fewer doctors and narrower lists of participation in some, if not most plans than currently exist for individual policies that have been available from the same carriers prior to 1/1/14.

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.Those who buy Blue Shield exchange policies will be able to use 12 of San Diego County’s 20 hospitals. UC San Diego Health System said all of its 820 local doctors are included. Anthem and HealthNet have not released the numbers for its doctors and hospitals. 

This pattern for trading discounts for relationships that could deliver high volumes of patients, does not appear to be unique to San Diego County.  “It is a common for hospitals and doctors to negotiate these types of arrangement where providers hope to gain more volume. But this strategy has not worked so well in San Diego County.

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.

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 "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.

1 comment:

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