Some doctors back away from Obamacare

Dr. Steven Larson is CEO of Riverside Medical Clinic, which has declined to be part of the California Covered insurance exchange, an outgrowth of Obamacare. Larson says the reimbursement rates are too low. (KURT MILLER/STAFF PHOTOGRAPHER)

This article originally appeared in the Press-Enterprise.

The Riverside Medical Clinics — with 140 doctors in five offices — is one of the largest providers of health services in the county. But it won’t be participating in the new health exchange marketplace called Covered California.

Dr. Steven Larson, the CEO, said he was taken aback when he saw what insurance companies were willing to pay. “The rates were 70 percent of Medicare [reimbursement]. It doesn’t leave room for making a living,” he said.

The clinics serve 300,000 patients under a variety of plans, including many Medicare patients who are not affected by the new exchanges. But the patients who want their care covered under a health exchange plan will now to have to look elsewhere for a doctor.

Larson wasn’t sure how many of the clinics’ patients would be affected. “It’s potentially a huge problem,” said Larson, who also is the chairman of the California Medical Association Board of Trustees.

Larson is not alone by any means. Many physicians around the state are grappling with insurers over participation in Covered California health plans. In some cases they are trying to decide whether to join. In other cases they are finding that they have been dropped from plans. And many are just trying to get information about whether they are listed in an exchange plan or not.

The struggle has serious implications for consumers who are trying to pick a plan in the exchange that will include their current physician. For uncounted thousands statewide, the answer is, it won’t.

To get coverage beginning Jan. 1 under Covered California, consumers must sign up by Monday. As the deadline approaches and uncertainty about the breadth of provider networks remains, odds increase that patients will show up for treatment next year thinking they have signed up for a plan with their doctor in it, and find out otherwise.

Covered California maintains that the plans offered through the exchanges include 80 percent of the state’s physicians. “We arrived at the 80 percent by comparing our network to the two largest commercial networks,” said Covered California spokeswoman Anne Gonzales.

But physicians and medical society chapters around the state aren’t buying it.

“The plans have no reason to be transparent about networks — the bigger it looks, the better for them,” said California Medical Association President Dr. Richard Thorp. “Many times when we look at their physician directories, they include names of people who have moved out of state, are retired or dead.”

Some physicians have been listed in the exchange after they refused to participate because of the low reimbursement rates.


Dr. Jennifer Hone, an endocrinologist in Santa Barbara, wanted to see for herself if she was listed among the providers in Covered California, even though the clinic where she works, American Indian Health Services, had opted out of the exchange plans over the reimbursement issue.

While on the phone with a reporter, she searched Covered California and found, to her dismay, that her name was erroneously listed as part of the Blue Cross network, and at the wrong address.

“I think people who signed up in Santa Barbara are frankly getting screwed,” Hone said. “People are being told by insurance companies that they can get coverage and that doctors are participating when in fact that’s a big fat lie.”

Covered California takes pains to note that the insurers, not the state exchange, are responsible for assembling lists of physicians. Doctors “contract with plans and the plans submit networks to us,” said Covered California’s Gonzales.

A cursory search of doctors listed in current insurance networks compared to exchange plan networks shows dramatic reductions.

In Riverside County’s 92503 zip code, for example, Anthem Blue Cross currently has 1,460 family and internal medicine doctors in its individual prudent buyer plan. Under its silver plan PPO in the state exchange, it lists 644 providers for the same zip code.

Blue Shield’s database showed a similarly shrunken network of doctors for the 92503 zip code: 1,429 versus 463 for the comparable Covered California plan.

In Modesto and Santa Barbara zip codes, the differences under Blue Cross were 577 vs. 367 and 257 vs. 87.

Anthem Blue Cross spokesman Darryl Ng insisted that it is not possible to make meaningful “apples to apples” comparisons of the health plans. However, Blue Shield spokesperson Lindy Wagner acknowledged that networks are getting narrower, citing one Covered California plan for individuals and families that will have only 60 percent of the physicians listed in a comparable existing plan.

Hone says she supports the Affordable Care Act’s commitment to expand health care access to those who could not afford it, which includes the vast majority of the 500 patients the clinic sees monthly. But the clinic decided to stay out of the Covered California exchange market because of reimbursement rates running at only 70 percent of Medicare.

It would be like getting $65 per patient “when it costs $100 to keep the doors open,” she said.

California Medical Association President Thorp said one of the health carriers also approached him with 10, 20 and 30 percent reimbursement cuts for three different plans. “And I said, ‘Thanks but no thanks.’”

Thorp, who practices in rural Paradise, was later informed he’d be included at his current rate because the insurance company didn’t have enough doctors in the area.

Covered California’s Gonzales said that insurers are required to increase the number of doctors in their networks if it turns out that there are too few to provide care for enrolled Californians.

Blue Shield’s Wagner said that to make Covered California plans affordable, insurers contract with providers at discounted rates in exchange for an expanded volume of patients.


Some doctors who said they would not participate in the exchange if rates were deeply cut are unsure whether they’ve been included in the exchange anyway.

“It’s been radio silence,” said Dr. William Lewis, an ear, nose and throat — ENT — specialist in Los Gatos. Lewis says about a year ago health insurers asked if he and other ENTs would take what he calls draconian cuts. Since then, he polled other ENTS in his part of Santa Clara County, and nobody has heard a thing.

Some doctors may have been included in Covered California exchange plans but haven’t been notified. Insurers are required to notify doctors if they’re included, according to Lisa Folberg, vice president of medical and regulatory policy for the California Medical Association.

That hasn’t always happened in Riverside, according to Dolores Green, executive director of the Riverside Medical Society. “Basically doctors don’t know if they’re in or out of the network,” she said. The society has told doctors to call the plans directly.

Larson said he will watch how the Covered California plans work, and in the future might talk to insurers about having the Riverside Medical Clinics participate. But he is not optimistic.

“I’m distressed that insurance companies don’t seem to care about quality, only cost,” he said.


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