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

[rodi]

I live in San Diego. Myself and my sons are on Kaiser Permanente HDHP's bought through the exchange. Completely happy with the coverage. I've never had any issue getting referrals to appropriate specialists.

My husband is on a Sharp HMO plan (see link above by Alldone)... Also purchased on CoveredCA. Sharp is, I believe, a San Diego specific chain. Same with Scripps. But I suspect there are similar plans in the OC.

Kaiser Permanente is a different model than many insurance models... It's closed network. The doctors are employees (vs private practice). You go to a Kaiser owned facility, see their doctors, nurses, PAs, etc. I've had long talks with my kids' pediatrician about this model - she LOVES it. Her hours are more reasonable, she has coverage when she gets sick or goes on vacation, she is allowed to spend part of her time pursuing her passion (NICU babies) and the rest of the time in her peds clinic practice. We've used her for 14 years. My primary also says the model is great for work/life balance for the doctors.... I've had my primary, also, for 15 years.

My husband made the change to Sharp when his primary retired.... the doc who took over the patients hadn't quite perfected bedside manner (young doc, new employee) and pissed of DH.... That could happen in any insurance model.

 

[MichaelB]

The anecdotes are real and I think there's no disagreement. That does not mean they represent the California individual health insurance market. The discussion in this thread is "doctors vs ACA", when it really should he "some health insurers behaviour".

Two large insurers were accused by state regulators of overstating their provider networks in 2014 and 2015. In addition to fines and refunds they are also subject to legal action by policyholder. Their actions led to numerous complaints that physicians listed in the network weren't taking the insurance. Investigation by state regulators showed this to be a systemic practice. The LA Times has covered this in great detail. One article

California regulators fined two insurance giants for overstating their Obamacare doctor networks and said the companies will pay millions of dollars in refunds to patients who paid too much for care.The state’s Department of Managed Health Care levied fines of $350,000 against Blue Shield of California and $250,000 for Anthem Blue Cross.
At issue were the companies’ error-riddled provider directories that frustrated many consumers statewide as they tried to find doctors during the rollout of the Affordable Care Act in 2014. As a result, some patients incurred big unforeseen medical bills because they unwittingly went out of network for care. California fines top health insurers for overstating Obamacare networks - LA Times

This issue has quieted down over the past year. That might mean it was resolved, or only the media losing interest. I suspect regulators scrutiny helped and insurers cleaned up their provider network representations. So, in response to the OP question, in California it appears that the key consideration is not whether doctors accept "ACA plans", it is whether the insurance networks include the providers.

 

[ivinsfan]

Wow 250 to 350 thousand dollars that will teach them to behave...the consumers had the refunds coming away due to the deceptions by the insurance companies..How about a little more bite to that penalty..that's just a slap on the wrist.

 

[Another Reader]

Small practices choose what insurance to accept. Most large health care organizations chose to work with the insurance companies and accept the ACA coverage from the beginning and modified their business and medical practices accordingly.

Every year the insurance companies threaten to drop Sutter Health from their networks here because they are too expensive, i.e. they are more aggressive in treating medical conditions and in monitoring their patients than the cheaper mega providers. Every year a deal gets worked out because Sutter is too big a player to cut off. The mega providers are starting to get better control of the situation. The little practices can't make it work, so they decline to participate.

Whether it's on Nextdoor or in a social setting, I routinely hear the same stories about providers not being in network or not accepting exchange policies (or Medicare) and having to find new providers if they can. Nothing has changed, except the war between the insurance companies and the mega providers is becoming more sophisticated.

 

[haha]

My husband made the change to Sharp when his primary retired.... the doc who took over the patients hadn't quite perfected bedside manner (young doc, new employee) and pissed of DH.... That could happen in any insurance model.

Can't a Kaiser patient request a new primary? My woman friend is covered in Seattle by Group Health, which has recently been acquired by Kaiser Permanente. She can request, and get, another doctor. Though there must be some controls or the docs who gave away the store would wind up with all the patients.

I think one thing in favor of a true HMO like Group Health or Kaiser has to do with specialists, especially surgeons. Surgery is like baseball, the more balls you take in batting practice, the better average you are likely to have in games. Many urban surgeons are under-employed, at least early in their careers, a time when their skills are likely near their max. In a big HMO, bad surgical outcomes other than death are likely to raise costs considerably. The managers really do not want this. Thus busy surgeons are likely to have better batting averages overall, and under-active surgeons are not part of an HMO business plan.

Ha

 

[daylatedollarshort]

The insurers have lists on their sites of the doctors and hospitals that are in-network. We check these lists before signing up for Covered California insurance every year. One family member needs a certain specialist so we pick a different plan for him that has the specialist on the list. It does mean if he needs hospitalization he cannot go to the closest hospital which is under 5 miles but has to go to one that is 10 miles away. But both plans have well regarded hospitals on their lists and pretty wide doctor networks, though not every doctor and hospital is on every plan.

California is a big state. If it were a country in terms of economic output it would be equal to France. Even with a plan network of 1/8 the doctors in the state you might be getting a larger network than if you lived in a smaller state where every doctor accepted every plan. As others have said you would need to know the overall statistics - anecdotes will not give you a comprehensive picture.

 

[Another Reader]

California is a big state. If it were a country in terms of economic output it would be equal to France. Even with a plan network of 1/8 the doctors in the state you might be getting a larger network than if you lived in a smaller state where every doctor accepted every plan. As others have said you would need to know the overall statistics - anecdotes will not give you a comprehensive picture.

The question is, are those 1/8 doctors the top 1/8 or the bottom 1/8? Since insurance companies pick based on how cheap and how malleable providers are, my guess is the average of the 1/8 is below the median.

 

[daylatedollarshort]

The question is, are those 1/8 doctors the top 1/8 or the bottom 1/8? Since insurance companies pick based on how cheap and how malleable providers are, my guess is the average of the 1/8 is below the median.

How do you know if any doctor is in the top 1/8 or bottom 1/8 regardless of insurance? And top of what? What is your criteria?

 

[travelover]

How do you know if any doctor is in the top 1/8 or bottom 1/8 regardless of insurance? And top of what? What is your criteria?

For sure. I'd bet that half of them are below average.

 

[daylatedollarshort]

For sure. I'd bet that half of them are below average.

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.

 

[photoguy]

Every year the insurance companies threaten to drop Sutter Health from their networks here because they are too expensive, i.e. they are more aggressive in treating medical conditions and in monitoring their patients than the cheaper mega providers. Every year a deal gets worked out because Sutter is too big a player to cut off. The mega providers are starting to get better control of the situation. The little practices can't make it work, so they decline to participate.

(1) Is Sutter health more actually more aggressive in treatment plans by any quantitative measure? or is this a conclusion based on anecdote?

(2) Does that aggressive treatment actually lead to be better outcomes or just more billing? There are lots of examples in medical literature where treatments don't actually help long term outcomes but of course result in greater remuneration.

(3) Is Sutter health more expensive due to point #1 (more aggressive treatment)? Or is it simply due to less competition at the provider level and more aggressive negotation with insurance companies? CoveredCA claims the greater rate increases in Norcal is due to less provider competition and not more treatment for the same problem. Of course CoveredCA might be biased but their argument based on the relative numbers of providers in Norcal/Socal makes sense.

 

[Brat]

In Portland Metro there are two highly rated Medicare Advantage plans: Kaiser and Providence. Kaiser NW includes much of SW Washington and now has a clinic in Eugene.

One of the members of my 50+ dragon boat paddling club had a serious accident (riding a motorcycle!!) near Bellingham about a year ago. He is a Kaiser NW Medicare Advantage insured. Kaiser life-flighted him from near the CN border to Oregon Health Sciences University Hospital where he spent several weeks. Then he was moved to a Kaiser owned rehabilitation facility in Portland where he spent a month or so. His road rash gave him MERSA in his wrist which has been dealt with. He talked to a couple Kaiser ortho specialists and feels that the best that could be done has been done and will leave well enough alone. The paddler was a hospital lab (not Kaiser) manager before retirement and is in a position to evaluate his care. He is back paddling.

We are using Kaiser and we can select physicians in their group. Some specialists require a referral but that hasn't been an issue with us. In fact my internal medicine doc insists that I see a couple of specialists even when I am inclined not to bother. Now they call me to lasso me in. If you want glasses or hearing aids (which you can purchase with a co-pay at Kaiser) you must see an optician or audiologist first, sometimes with a couple week's wait. My husband likes a particular dermatologist who must be kicking 70 and is working part time. He has been offered others but says he will wait until her schedule is posted. She has quite a following, and an attitude, which makes husband's appointments interesting.

 

[rodi]

Can't a Kaiser patient request a new primary?
Ha

They can - but he chose to bail to Sharp. I argued against switching because I prefer the Kaiser model. There are good doctors and bad doctors under any insurance model... he just hit a bad one and chose to change insurers, rather than doctors.

 

[Salty]

Thank you to everyone for your thoughtful replies. At the very least, it sounds like it is far less certain in California that most any doctor or hospital will accept Covered Ca plans, although there certainly seems to be a wide variety that do. I guess the real test and challenge is that circumstance when you get a serious illness, and want the BEST care for that type of illness. One Boston hospital here, advertises that " Your doctor may have seen your type of cancer, but WE see it everyday!"
That is where I get nervous. What if your ideal specialist is at Cedar Sinai and you live in South OC?

Regarding Kaiser, I am curious, we do not have anything like them here. They are well rated on the Covered CA website, yet my sister while lives in CA, has story after story about people who were denied the care they needed, ( and one died).

I guess where my concern lies is not so much with the day to day, but the serious cases ( that we pray we never get). The fact that even " some" of the posters have had experiences where Drs do not accept Obamacare can make one nervous-

 

[Brat]

I have not come across anyone who has personal experience with a friend or family member who has been denied needed care by Kaiser. Back in the day I would hear of a friend of a friend whose aunt said... but back then the AMA was fighting the Kaiser model. Now if you think Laetrile is a cure for cancer (as did a co-worker) Kaiser probably is not the health care provider for you.

 

[daylatedollarshort]

We had a family member needing specialized surgery and our Kaiser doctor said they would have one of their staff doctors to do it - someone who did maybe three a year. We switched plans to use a specialist who has done thousands of this type of surgery instead. I don't want one of my family members to be a practice patient for major surgery. The surgeon we went to is actually is not on any insurance plan - he can set his rates as he pleases since he has specialized skills, but we picked a plan so the hospital and support services he uses are all in network.

We had other issues with Kaiser, too, like packed ER waiting rooms and overworked staff when the regular local hospital usually had no one waiting in the ER and attentive care.

That's my anecdotal experience.

 

[haha]

We had a family member needing specialized surgery and our Kaiser doctor said they would have one of their staff doctors to do it - someone who did maybe three a year. We switched plans to use a specialist who has done thousands of this type of surgery instead. I don't want one of my family members to be a practice patient for major surgery

Good move. Were you able to do this on the fly, or did you have to put the procedure off until year-end open season?

Ha

 

[daylatedollarshort]

Good move. Were you able to do this on the fly, or did you have to put the procedure off until year-end open season?

Ha

It was not an emergency surgery, so we had some time to research the best surgeon. Then during open enrollment we picked a plan that had the hospital the surgeon was affiliated with in their preferred provider network, so at least the hospital was in network and the insurance covered some but not all of the surgeon's fees.

 

[Brat]

Often Kaiser will opt for an out of 'network' surgeon. For years they used a well known heart surgeon who was not a Kaiser physician and didn't practice at their hospital. http://www.ohsu.edu/xd/health/services/heart-vascular/about/starr/profile.cfm Bottom line: better results, cheaper for Kaiser.

You obviously researched insurance policies available to you, the same thing could have happened with any other PPO.

 

[daylatedollarshort]

Often Kaiser will opt for an out of 'network' surgeon. For years they used a well known heart surgeon who was not a Kaiser physician and didn't practice at their hospital. Dr. Starr's Profile | OHSU Knight Cardiovascular Institute | OHSU Bottom line: better results, cheaper for Kaiser.

You obviously researched insurance policies available to you, the same thing could have happened with any other PPO.

I don't know how many specialist kind of surgeons Kaiser has on staff compared to statewide PPO networks in California with the big insurance companies to know. There is also the ER room issue and a lot of things I didn't write up. YMMV. I personally am not a Kaiser fan based on my family's experiences for many issues.

The hospital the specialist surgeon operates at did have a long list of insurance carriers and plans they did accept.

 

[Another Reader]

Kaiser did that for a complex pediatric heart case (child of a coworker). Multiple surgeries were done at Stanford. This was more than a decade ago, but I got the feeling it was cheaper to send the occasional patient out than to have a staff of surgeons capable of this level of work.

 

[Another Reader]

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....

 

[Disappointed]

I am from CA. When I retired in 2014 I signed up with Covered California, Blue Shield of California Gold 80/20 PPO policy, it cost $1,270/mo, husband and wife. I pay $1,362/mo now. I chose the Gold level to make sure that I am not restricted to a narrow network. I have not had problem accessing world class cares, from UCLA, USC, to private practices. I have had several MRIs, Ultrasounds, Biopsies, MOH surgery, Genetic Tests, Eye Specialists, etc., no problems.

There are private practices that do not take any insurance at all but these are minorities, based on my experience. Whenever I am seeing a new doctor, I would call their office to confirm that they accept my insurance. I have yet been in a situation where I was unable to find specialists that I needed.

The network directory was not as accurate in the beginning but has gotten a lot better, still it is better to call to verify that your insurance is accepted.

Give Blue Shield of California a try.


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Mp

 

[Scuba]

I have never tried Kaiser but my feeling is if one can afford it, why not have maximum choice? If DH or I got cancer, I want to be able to go to the best docs, get the most advanced meds and treatments. All of the managed care organizations are VERY focused on managing costs. That priority could be a conflict of interest if we ever need state of the art, expensive treatments. We will keep our "grandfathered" pre-ACA PPO plan as long as we can afford it.


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[plsprius]

I am surprised no one has mentioned the Consumer Reports write-ups on Health Insurance.

This publication is a good resource on all of these issues, and rates Kaiser very highly: Best Health Insurance Ratings & Reviews - Consumer Reports

You need to be a subscriber to click to the actual rankings, but much of the info is open. If you are really interested, go to your local library.

Disclosure of bias: I have been a satisfied private pay (now ACA) Kaiser member for 20+ years.