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Insurers limiting doctors, hospitals in health insurance market

Insurers in California's new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.

September 14, 2013|By Chad Terhune
  • Major insurers have limited the number of doctors and hospitals available in California's new health insurance market. Cedars-Sinai Medical Center, for example, is available only on two lower-priced Health Net plans in the state-run market.
Major insurers have limited the number of doctors and hospitals available… (Kirk McKoy / Los Angeles…)

The doctor can't see you now.

Consumers may hear that a lot more often after getting health insurance under President Obama's Affordable Care Act.

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.

QUIZ: How much do you know about health care?

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. 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.

GRAPHIC: Prices in California's health exchange

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."

Rather than mere head count, officials say they are scrutinizing what capacity physicians have to accept new patients. And to assist consumers, California will enable people to search for specific doctors online during enrollment to determine what, if any, health plans they will be part of in Covered California.

"Does the doctor have room for one more patient or 40 patients? It's about available seats," Lee said. "We want to make sure every network has enough doctors."

Health Net says price will probably matter most to the uninsured and people who buy their own health insurance now, so it built a narrow network to serve those "value seekers."

"We have more than enough doctors for our projected enrollment through 2014, and we have time to adjust if it becomes necessary," Health Net spokesman Brad Kieffer said. "We continue reaching out to providers, and we are bringing more on board."

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.

Insurers and some consumer advocates think people are willing to trade some choice in order to pay less. More employers have been adopting these narrower networks in recent years to trim their own healthcare bills.

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.

Covered California says it's still compiling a list of all providers for the 12 health insurers in the exchange.

Supporters of the healthcare law say these types of problems are inevitable in rolling out such a massive program. Overall, they say, millions of consumers stand to benefit from guaranteed coverage regardless of preexisting medical conditions and the protection from financially crippling medical bills.

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