Keeping Your Doctor Under Obamacare Is No Easy Feat

The reform law is narrowing care networks

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Joe Raedle / Getty Images

From left: Narendra Parmar sits with Certified Enrollment Specialist, Laquanda Jordan, as he finishes the process of picking and signing up for health insurance through the Affordable Care act at a Miami Enrollment Assistance Center on Dec. 23, 2013 in Miami.

When Blue Shield of California was designing the new health plans it would offer individuals under the Affordable Care Act (ACA), the insurer made a simple request to doctors and hospital in its network — lower your prices or get left behind. The insurer asked providers to accept reimbursement rates as much as 30 percent lower than what Blue Shield previously paid through plans sold on the individual market.

Some providers got on board, but not all. According to the company, just 60 percent of the doctors and 75 of the hospitals that participate in the Blue Shield of California’s group plans will be included in individual plans purchased through Covered California, the state’s new insurance exchange. And among the providers who declined to accept the lower rates were some of the state’s most prestigious — and expensive — hospitals, including Cedars-Sinai Medical Center in Los Angeles and hospitals affiliated with the University of California.

As millions of new ACA health plans begin 2014 coverage on Wednesday, consumers in some parts of the country, including California, will find that the plans offered under Obamacare give them access to fewer providers than their previous plans or those offered to Americans with job-based health insurance. Narrowing networks — promising select providers higher patient volume in exchange for lower reimbursement rates — is nothing new, but as insurers compete on price in Obamacare’s new exchanges, avoiding expensive hospitals and doctors has new appeal, especially since insurers can no longer exclude sick people or charge them more. “Our goal was to provide affordable options for California consumers and there are few levers we have to get to an affordable price point,” says Steve Shivinsky, a spokesman for Blue Shield of California. “One of them is to ask the providers to contract with us at new rates and that led to smaller networks.”

A recent study suggests limited provider networks could become more common in the years ahead as the ACA takes hold. A Dec. 13 McKinsey study of 20 U.S. metropolitan areas found that two-thirds of ACA plans analyzed had “narrow” or “ultra narrow” networks, with at least 30 percent of top 20 hospitals excluded for coverage. The medium premium for plans with narrower networks, according to the study, was 26 percent lower than comparable benefit packages with broad networks.

“We’re very concerned with the impact that has on patients,” says Cedars-Sinai CEO Thomas Priselac, arguing that consumers shopping through California’s exchange will not have access to the world-renowned health care the hospital offers. Priselac says some insurers designing networks purely based on cost have replaced academic research institutions like Cedars-Sinai with lower-priced community hospitals that, in some cases, do not offer the same menu of services. Seattle Children’s Hospital, the top pediatric facility in northwest Washington state, and one of the most expensive, sued the state insurance commissioner in October after hospital was excluded from the networks of some insurers selling plans there under the ACA.

But while some might say insurers are sacrificing patient choice and quality in service of the bottom line, there’s another way to look at the narrow networks being offered through Obamacare. “Everyone needs to commit to thinking about ways to reduce the unsustainable year over year increases in the cost of health care,” says Shivinky of Blue Shield. Doctors and hospitals are now under new pressure to lower prices to get access to the flood of new customers shopping for insurance through the law’s exchanges.

“This is market competition,” says Karen Pollitz, a senior fellow at the Kaiser Family Foundation who studies the insurance market. “Whether you like it or not, this is what we signed up for.”

Pollitz, who worked for the Department of Health and Human Services helping to implement the ACA before taking a post at Kaiser, says it’s not clear if hospitals like Cedars-Sinai will lower prices to attract customers through Obamacare’s insurance exchanges. Consumers who buy insurance independently — the population the exchanges are built for — are a relatively small piece of the overall insurance market, meaning some providers may be able to ignore them without suffering financially. Priselac, of Cedars-Sinai, says it too soon to know if the hospital’s exclusion from most ACA plans in California will hurt the hospital’s bottom line. But, Pollitz says, ”in a city like L.A. that has a gazillion hospitals, it’s easier to kick a big one out.”

In other areas, the effects of narrow networks may be more acute. In Maine and New Hampshire, Anthem, a dominant provider of individual market insurance policies, excluded a number of large hospitals in those states  from its ACA plan network. For some residents in rural areas, according to Pollitz, this means they may have to drive long distances to get to in-network hospitals. “If you’re in central Maine, you have to go to Portland to find a hospital and some people were kind of upset about that,” she says. Texas Oncology, the largest cancer care practice in the state, said it has decided not to participate in the networks of any insurers selling 2014 policies through the Texas ACA exchange. Elsewhere, stories of major health care providers choosing to sit out next year’s ACA plans — or being excluded by insurers — are piling up.

In a report released Dec. 11, Covered California said more than 80 percent of doctors in the state are included in the network of at least one insurer selling plans through the exchange. Still, Dr. Jeff Rideout, the exchange’s senior medical adviser, concedes that many individual plans have networks that include fewer providers than non-ACA plans offered by the same insurers. But, he says, there is more upside than just lower prices. “Better value occurs when there’s better alignment between a plan and a relatively tight network,” says Rideout. In other words, when insurers and providers are more dependent on each other, there’s more motivation to deliver efficient care. Integrated health systems that provide both insurance and care have, in many cases, some of the country’s best health outcomes at the lowest cost. Very narrow networks may have a similar effect.

“It’s potentially a great thing, but the devil is in the details,” says Rideout.

97 comments
PANATAG
PANATAG

pagtatanggol laban terorista at gustong maghasik ng gulo 

"imperialista o colonialista" 

hindi para sa kasamahang nais biktimahin

at mas lalong hindi dapt ipagamit para sa 

personal interes ng manlulupig/sadistang "AMO" at 

lalong hindi upang GIPITIN AY GAWING HUWAD NA SAKSI* 

que horor   

Health CareKeeping Your Doctor Under Obamacare Is No Easy Feat

The reform law is narrowing care networks

By Kate Pickert @katepickertJan. 01, 201492 Comments



Read more: Obamacare: Keeping Your Doctor No Easy Feat | TIME.com http://swampland.time.com/2014/01/01/keeping-your-doctor-under-obamacare-is-no-easy-feat/#ixzz2pKTvljEQ

ReneDemonteverde
ReneDemonteverde

I thought that if you like to keep your doctor you can keep your doctor, period. What Obama really meant was If you want to keep your doctor you can keep your doctor, comma but.......There will be enough idiots on this page to justify, defend ,deflect misinterpret what Dear Leader meant.


WellRead
WellRead

Just like any other government -funded medical plan, Docs will ignore ACA plans as much as possible, especially if their clientele have jobs, many of which come with health insurance.

The EXchanges signaled to carriers what pricing they wanted (unrealistically low) and then told them they couldn't hit the price by changing coverage or customizing coverage to age or gender.  That left them with only one option to hit the price points, break out their highest cost hospitals and docs. 

These are typically the most sought after hospitals and docs by consumers.

Just like in Medicaid, and Medicare, consumers who buy the "govm't plan" are getting less care than their brethren who have prvate coverage through a job.

WR

gotrr
gotrr

Doctors, like everyone else, will have to get on board with the ACA. Not taking Blue Shields well-priced California plans? Then, they'll have fewer customers. Period. People may like their doctors, but if they can't afford to pay them, then they have to make a choice.

j45ashton
j45ashton

Well, I've have some experience in these areas.


First, the illusion about people coming here for treatment.  It's true.  Those who are rolling in dough do come here for certain treatments.  Why wouldn't  they if they're completely loaded?  As to everyone else, I used to work internationally and I used to ask people in Canada, Spain, Holland, UK if they would rather change over to our form of taxation, insurance & medical treatment.  They all had complaints about their systems, but not one of them said yes, they wanted to change to ours.


So the ACA is saying it wants to pay for quality results, not batteries of unnecessary tests.  What's wrong with that?  I had a close friend who suffered serious neurological damage.  Was in a hospital bed on intravenous feeding, unable to move, eventually passed on.  For several weeks a neurologist came in every day to test her reflects.  For a 2 minute test he charged $100 per test when it was well known she was quite beyond hope,  What about doctors like that?  Her family refused to pay any more than what medicare covered.


Sure, I want good doctors to pay their bills and make a  good living.  Some doctors aren't so good.  I don't care if we lose them.  Some can't get into medical school here, they go overseas & come back rake it in.  A friend just visited a urologist for the first time.  One with a good rep.  Ran standard tests.  For a 1/2 hr visit and 4 tests that were completed in the office, the full billing came to over $1200.  Wow.  Medicare paid about $200. He had to pay about $200.   It was astonishing to see his bill...how much the Dr charged vs how much Medicare was willing to pay.  One sonogram, $400.  My friend got 3 types of pills that all made him sick.  Dr said surgery was the only alternative.  But my friend went on a diet, started exercising & got careful about fluids.  Net result:  80% better.


5 years ago I had a dentist take over for my regular who retired.  Told me a I needed an immediate root canal.  Went to my wife's dentist.  Crystal clear x-rays told a different story.  No root canal needed, no problem in 5 yrs.


So that's the mill now.  Get them in, give them a battery of tests, prescribe some pills, charge plenty, and call out "Next".


So now according to some doctors they're going broke & we have to pass the cup for them.  And yes, according to some GOP conservatives, the sky is falling.  (When is doubt, resort to fear-mongering...the GOP mantra.)  Doctors are leaving the country (probably to go on vacation), there won't be enough doctors, we're all going to die in the streets and turn into zombies.


No, it's just like my former doctor who stopped taking medicare and then started taking it again.  There are changes coming.  Like it or not, if doctors want to stay doctors, they'll have to make some adjustments...and no, the sky is not falling.  They are just some with vested interests who want people to think so.




ReformedRep
ReformedRep

Kate, thanks for this article. Now I want to ask you to go one step further and actually do some real digging and reporting on the details.

You chose BS of CA to focus on, the same folks who screwed their rating so badly a few years ago that the state challenged them only to find 18-20% "errors".

First, we need an actuary to explain how rates can go up while reimbursements go down so much. Yes pre ex and new benefits are there but much if the individual market was also already insured and had been underwritten. So higher premiums, lower reimbursements = insurance company rip offs.

At leas the MLR is there if they are overcharging but they get 20% of a much larger number to work from. Gee, I wonder of that ever dawned on them?

Here in GA the only major insurer with a broad network is Humana. The cost difference is 6-7%.

Hmmm. How can that be?

I have seen several reports of major hospitals that were never even asked to participate in the new networks. Augusta GA jasmine, WA did as well as NY. I am sure there are others . How does this happen.

This is the real story of the laws rollout. A last, brazen attempt by the insurers to rip off the public since they no longer can discriminate at will,and sell crappy policies.

Also the flip side is why isn't Issa and his committee all over this? Oops he is a Repub.

BellaMia7
BellaMia7

The terrifying headlines coming out of the UK single-payer system include:


"60,000 euthanized without consent"

"20,000 appointments cancelled due to doctors' strike"

"Breast cancer betrayal of older women:  Only 1 in 7 over 70 receiving chemotherapy"

"Patients going blind on waiting lists for eye surgery, doctors frustrated."


And many more. They ration care to the seniors, and very young.  Tragic.

firmsoil
firmsoil

"If you like your plan...." -  Barak Hussain Obama (A dishonest person who is the sitting US president).

j45ashton
j45ashton

About 3 years ago my doctor stopped accepting medicare..  So I found a better doctor.  Much more detailed.   Some doctors are going to drop out of programs that they feel don't pay enough.  If enough people simply stop going to these doctors, guess who loses.  I just saw that my old doctor is now back to accepting medicare again.  There are enough really good doctors out there for whom the money is not the big issue that the AMA would have you believe it is.  Find those doctors, give them your business.

wisited_me_not
wisited_me_not

@ReneDemonteverde  and everything is about you, Rene.  Six years ago my partner's insurance company cancelled  his policy  three months AFTER his death and returned the premiums back to my credit card.  During his illness they denied procedures and Chilton still racked up thousands of dollars.  Guess who eventually paid for those medical costs under the broken "private insurance" system?

manlyman
manlyman

@gotrr  No they don't have to get on board with the ACA. They can quit. And many already have. It's creating a shortage of doctors, that's as plain as can be, and that can only decrease the quality of care, there's no other way around it.

reallife
reallife

@j45ashton  "Well, I've have some experience in these areas."


you mean misleading, lying, misrepresenting?


yup, we noticed



ReformedRep
ReformedRep

Thank Gof the ACA is a private plan and not at all like NHS

TariqAhmed
TariqAhmed

@BellaMia7 Feel sorry. But let us keep our health in our own hands: skip alcoholic beverages, cigarettes, exercise diligently, sleep more and often, watch what you eat etc. Heath-care, like diamond, are not for all, forever and without payments. Ask your government to eschew war and its armaments that take away money from health-care.

barneydidit
barneydidit

@firmsoil Blah Blah Blah says the guy who voted for  George "they have WMD's" Bush...twice. 

nmsoxfan1
nmsoxfan1

@j45ashton "money is not [a] big issue" for me, but I need enough to live and care for my family.  Doctors often have $100,000 or more in student loan debt that is NOT dischargeable in bankruptcy.  The admin's solution to heath care costs is to cut payments to providers.  That will mean fewer and worse providers.  There is already a significant doctor shortage in this country and it will get much worse under O'care.  You may have a found a "better doctor," but millions of other people will not think that has occurred for them.  Canadians, Mexicans and people from many other countries have come here for health care for decades.  O'care will mean that any American who can afford it will go elsewhere for their care.  Maybe the good providers now in America could set up shop on the ocean outside the three-mile limit, like casino ships used to do.

j45ashton
j45ashton

@reallife @j45ashton  Not sure what you myopically noticed.  Either you're a troll, a doctor, a kid, a fool or someone who somehow has escaped serious experiences with the medical establishment so far.  You'll  wise up!  There are plenty of people with a little more experience or smarts than you who know too well how they've been treated and billed.Edit (in 5 minutes)



ReneDemonteverde
ReneDemonteverde

@TariqAhmed@BellaMia7But you cannot escape from the depression and uncertainty which will probably occur once Obama Care is in full swing. Depression also cause mental, physical and emotional problems.

firmsoil
firmsoil

@TariqAhmed

Your way of life teaches supporting Hussain Obama's lie as you do here.

ReneDemonteverde
ReneDemonteverde

@barneydidit@firmsoilFrom a person who voted somebody for President all because he is black and probably as added bonus, sings like Al Green. Look who is talking.

57nomad
57nomad

@barneydidit@firmsoil 

@barneydidit@firmsoil  

Barney, what was that about Bush again? 

"One way or the other, we are determined to deny Iraq the capacity to
develop weapons of mass destruction and the missiles to deliver them.
That is our bottom line." --President Bill Clinton, Feb. 4, 1998

"If
Saddam rejects peace and we have to use force, our purpose is clear. We
want to seriously diminish the threat posed by Iraq's weapons of mass
destruction program." --President Bill Clinton, Feb. 17, 1998

"Iraq
is a long way from [here], but what happens there matters a great deal
here. For the risks that the leaders of a rogue state will use nuclear,
chemical or biological weapons against us or our allies is the greatest
security threat we face." --Madeline Albright, Feb 18, 1998

"He
will use those weapons of mass destruction again, as he has ten times
since 1983." --Sandy Berger, Clinton National Security Adviser, Feb, 18,
1998

"[W]e urge you, after consulting with Congress, and
consistent with the U.S. Constitution and laws, to take necessary
actions (including, if appropriate, air and missile strikes on suspect
Iraqi sites) to respond effectively to the threat posed by Iraq's
refusal to end its weapons of mass destruction programs." Letter to
President Clinton, signed by: -- Democratic Senators Carl Levin, Tom
Daschle, John Kerry, and others, Oct. 9, 1998

"Saddam Hussein has
been engaged in the development of weapons of mass destruction
technology which is a threat to countries in the region and he has made a
mockery of the weapons inspection process." -Rep. Nancy Pelosi (D, CA),
Dec. 16, 1998

 


firmsoil
firmsoil

@barneydidit

Obama's quote is the lie of the year 2013; there is no Bush quote "thay have WMDs" liar barneydidit.

ReformedRep
ReformedRep

All my doctor friends are moving overseas.....LOL. Where do these types of fantasies come from?

yahtahhey
yahtahhey

@nmsoxfan1 @j45ashton 


Doctors are private economic entities.  They  don't have to sign up with any insurance company.  They don't have to take Medicaid or Medicare, for that matter..  The reality is they have to take Medicare and at least the better paying plans to keep the doors open.  So their profits get squeezed as Obamacare injects more competition into the system in the form of somewhat standardized policies.  That's why the prices are low on the policies.  


We don't have to do it that way.  We could go to a National Health Service model which is already used for the Indian Health Service.  Government pays for medical school and residency.  Doctors are commissioned officers in the Coast Guard and assigned to Indian hospitals.  They don't worry about malpractice.  They don't worry about back office matters.  They show up for their shifts and practice medicine, period.  The doctors don't get rich like they used to in the old days, but they get better than average incomes.  Its not a bad trade-off.  

ReneDemonteverde
ReneDemonteverde

@PaulDirks@ReneDemonteverdeWhat you consider rip offs are not rip offs to others. Just as a used car salesman selling a lemon to you might earn your admiration and respect, there are people who demands more from their President.

ReneDemonteverde
ReneDemonteverde

@PaulDirks@ReneDemonteverdeJust answer the question. Did Obama said what he said or not ? Just many of the libturds in this page you do not answer directly but try to deflect to other irrelevant topic. HE LIED.He should not have lied after promising transparency. HE LIED. Deal with it. Now let the shift to George Bush mistakes begin.

ReneDemonteverde
ReneDemonteverde

@La_Randy @ReneDemonteverde @barneydidit @firmsoil Nothing, it seems now that it is a prerequisite for qualification to seek the Presidency. Since Obama seems to have no other competent skills as President, let us include that in his record . He will not release his academic records but to show he is qualified he sang his version of Al Green

GREAT.

mantisdragon91
mantisdragon91

@57nomad@barneydidit@firmsoil 

And yet all those comments came before the UN inspectors on the ground in Iraq clearly stated they have no WMDs. Why the rush to get them out and invade? More importantly why the coverup of the Saudi government involvement in 9/11?

firmsoil
firmsoil

@57nomad

Like his leader Hussain Obama who lies barneydidit lied about the Bush quote "thay have WMDs" above.

DarleneRitterGoodfellow
DarleneRitterGoodfellow

@firmsoil Squawking about the "Lie of the Year" by a fact-checker that had previously determined the statement to be "Mostly True" is a little ridiculous, don't you think?