Doctors in Southern California not accepting " Covered California" plans, even PPO's

[rodi]

As far as specialists at Kaiser. My husband had some a-fib issues several years back and was sent (by Kaiser) to a cardiologist at Scripps Memorial (non-Kaiser). This was bonus for us because it's much closer to our home.

My mother's ovarian cancer doctor was a super well respected "super doc" (major publications, etc.) Her chemo was managed by the regular oncologist - but under the supervision of the gyno-surgical super doc dude... When comparing notes with other patients - turns out this was the go to guy, and folks had actually switched to Kaiser to be able to use him.

In any insurance, getting a good primary doc is important. My dad's 2nd cancer experience (multiple myeloma)... he went in with shoulder pain... and the doc kept at it until they figured out it was blood cancer. My dad was kvetching the whole time about how the doc was trying to slap a terminal illness label on him. (Which it was... but that is not the doctor's fault). I have been very impressed with their oncology docs.

 

[ziggy29]

I had Kaiser for most of my life when I lived in California. From my experiences and in talking to others, you either loved it or you hated it. We had a major Kaiser facility within a mile of our home, so we mostly loved it. There are catches -- it can (at least back then) take a bit longer for a routine appointment and generally (unless referred by Kaiser or emergencies) you are limited to Kaiser facilities for coverage. But there were no claim forms and, again at least at the time, little to no fighting with the insurance bureaucracy: if a Kaiser doctor declared a procedure to be medically necessary, it was covered.

I think I have shared this story here before but it bears repeating. In 2000, DW was recommended for braces and the orthodontist recommended jaw surgery to correct the jawline before the braces went on. As far as we can tell, that wasn't usually considered a necessary covered service under many medical plans. But we went to a Kaiser doctor who referred us to a specialist in orthognathic surgery at a Kaiser facility in Oakland, about 40 miles from where we lived at the time. He reviewed the orthodontist's findings, took some X-rays and concluded it would be medically necessary in order to minimize almost certain head and TMJ problems in the future. So all we paid (remember this was 16+ years ago) for the surgery was a $10 copay. Normally the procedure would have cost in the $15-20K range. We didn't have to fight it or take it to insurance company bureaucrats and beancounters. A Kaiser doctor indicated it was necessary, so it was covered -- end of story.

So yeah, we sort of became Kaiser fans after that. I don't know if that model still fully applies there (and I know it would be a lot more than just a $10 copay!), but at the time, it takes a LOT of the "are they or aren't they in the network" stresses out of the picture. Treated by a Kaiser doctor, in a Kaiser facility, at the direction of a Kaiser PCP and specialists.... it's covered with no potential for balance billing sticker shock. If we lived in a region that was served by Kaiser and we have sufficient facilities close by, yeah, we'd go back.

 

[rodi]

ziggy - I had a similar discussion with a Kaiser doc about what might be considered an optional surgery. I was pregnant with my 2nd son, and my mom had died of ovarian cancer 2 years previously. Kaiser offered to do tubal ligation (if you requested it in advance) if you had a c-section... in order to take advantage of you already being opened up, surgically. I asked my doc about whether I could do a prophylactic oophorectomy instead of tubal ligation if I ended up with a c-section... we discussed my reasoning (family history of ovarian and breast cancer... the fact that I was already in my 40's and so not that early to trigger menopause.) She said it was unusual, but I had a compelling case. We also talked about the downsides (issues with nursing the baby, etc.)

I was very impressed that the doctor could approve it - it would be covered, if you had legitimate medical concerns. I ended up not doing the surgery because I didn't have a c-section and then decided to just let nature take it's course.

 

[daylatedollarshort]

Kaiser was a good idea for the Kaiser employees that had no health care for themselves or their families. The concept did not grow well. Once every employer in the East Bay saw the benefit, Kaiser became overcrowded and the quality of care deteriorated to that of the County hospital in Oakland. I could tell you over 50 years of Kaiser horror stories.

Things might be better at the Kaiser facilities outside of the Bay Area. The patient and employer demographics are probably better in San Diego and other higher income areas. But I would not enroll in Kaiser here under any circumstances. Too many bodies....

That pretty much sums up my experience. The local ER situation alone is enough to keep me from ever going back. We have Blue Cross now and have been happy with their plan and PPO network.

 

[rodi]

I'm surprised by the ER comments. As you all know - last year was the year my sons decided to have a variety of ER requiring sports injuries. In everycase they did appropriate triage and we were taken back quickly. In fact, with my son's broken face (baseball at high speed to the orbital socket) they pulled us out of line before we'd even checked in. I guess the blood and swelling were clues. LOL.

We had a much longer wait at Sharp Hospital (DH has Sharp HMO) when he had to go to the ER last fall.

One more thing I like about Kaiser is their urgent care system. As a mom with kids that used to spike fevers during non-office hours - this was awesome. Just last week I used urgent care for my son's sore back-hip. My ped was on vacation so they suggested urgent care. My son was seen quickly and the dx was prompt and treatment seems to be working.

 

[Scuba]

Good to hear so many people like Kaiser. We may end up there someday. The Lynette Rahm case scared me a bit - young girl won $28M lawsuit because not one but two Kaiser docs refused her an MRI and she lost her leg, part of her spine and pelvic bone when it was finally diagnosed as cancer 2+ years after her parents asked for MRI to be done. I don't think docs in independent practices would have been so hesitant.


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[Brat]

Heck, a playmate of one of my kids had a diagnosis of asthma by her non-Kaiser pediatrician, the mother was very concerned and needed an ok for her daughter to play soccer - approval granted. One day, nebulizer at the ready, the child collapsed on the soccer field and died. She had a hole in her heart, not asthma.

IMHO seek second opinions, even third opinions. If you pay for an MRI that wasn't prescribed and it identifies the problem send the MRI bill to the insurer. Kaiser NW will pay for a second opinion and the docs at a place like OHSU have no compunction about offering a different point of view. Even if you end up paying the bill at least you know every last possibility has been explored. Trust but verify.

Physicians make mistakes, a Stanford neurosurgeon make a big one years ago while treating a cousin's wife (CA public employee's insurance). There is a reason why doctors carry malpractice insurance.

 

[ziggy29]

Good to hear so many people like Kaiser. We may end up there someday. The Lynette Rahm case scared me a bit - young girl won $28M lawsuit because not one but two Kaiser docs refused her an MRI and she lost her leg, part of her spine and pelvic bone when it was finally diagnosed as cancer 2+ years after her parents asked for MRI to be done. I don't think docs in independent practices would have been so hesitant.

Yeah, I know. The thing is, there are millions of data points every year, no matter where you go. There are always going to be a handful of really bad decisions and bad outcomes. I think the best we can do is look at (relatively) objective statistics on outcomes and instances of fighting the insurance bureaucracy. I haven't looked into those for Kaiser in the last 13+ years since we moved to a place where they aren't around.

 

[daylatedollarshort]

Ooops, my bad. I should have typed earlier that we currently have Blue Shield, not Blue Cross. We helped one of the kids buy an Anthem Blue Cross policy more recently so Blue Cross was on my mind. So far so no issues with either one.

 

[HadEnuff]

This is probably an old joke but it was new to me. A dental student friend asked me what do you call the person who graduates last in his dental class? The answer was a dentist.

Actually, the answer is "Doctor".

 

[rrppve]

In SoCal, Covered California offers 2 different PPO networks, Anthem and Blue Shield. Originally when Blue Shield started offering CoveredCa plans, they went to their doctor network and said if you want to be included in our CoveredCA network, we are cutting your reimbursement 30% for all of our plans. Many private physicians opted out of the Blue Shield network. This caused a lot of issues with access. Over the last 2 years, Blue Shield has expanded their network, but it is still smaller/narrower than the one offered to their group plans. Nonetheless, the major research hospitals are all included and the network actually is pretty good now.
Anthem had the broader network originally. However, they started narrowing their network in the last couple of years and there are now a number of specialists who previously took Anthem CoveredCa plans who no longer do. Also, Anthem has proposed a major rate hike for 2017.
Thus, it looks like I'll be switching from Anthem to Blue Shield for PPO access next year.
I've tried to get actual data on the breadth of Anthem vs. Blue Shield's network, but have been unable to find it. They both say to check individual doctors using their tools. I've had a dermatologist and neurologist drop out of Anthem since we enrolled, but good alternatives have been available. Also no problem seeing a world class specialist at UCLA.
If you are willing to sacrifice physician choice and want a HMO, Kaiser is clearly the best in SoCal. However, you will need a good advocate to get you the treatment you want/need in a timely manner. Great specialists available at Kaiser Sunset, but you need to navigate the system. There is a tendency to just stabilize and get rid of the patient as opposed to finding the underlying cause and treating it.
All anecdotal experiences.