© 2022 KVPR | Valley Public Radio - White Ash Broadcasting, Inc. :: 89.3 Fresno / 89.1 Bakersfield
NPR For Central California
Play Live Radio
Next Up:
Available On Air Stations

California Health Insurers Restrict Doctor Choice To Lower Costs

Pauline Bartolone
Capital Public Radio

As Californians shop for new insurance under the federal health law next year, they’re faced with many choices for health plans at different prices. But the plans they choose also come with different combinations of doctors and hospitals. And as Health Care reporter Pauline Bartolone tells us, some people are confused and frustrated by the new conditions.  

Diane Shore of Mill Valley is one of a small group of Americans who received a letter that their health policy will be canceled. The letter from Blue Shield of California suggested a new Blue Shield plan with a small premium increase. But she’s not pleased.   

Shore: “My physicians will no longer be in this network of physicians, or the hospitals won’t be as well.”

If Shore chooses that Blue Shield plan, the doctors and hospitals available to her will be limited to certain geographic areas, like Marin County where she lives.

Shore: “All my doctors are in San Francisco. I live 20 minutes from San Francisco. In fact, it’s more convenient for me to go to San Francisco than to the hospital here in Marin County.”

Shore says she wants to stick with the providers that she’s had since she battled breast cancer in 1998.

Shore: “I want to keep with a surgeon that I know if this ever reoccurred, that I have full confidence in her. And my primary care doctor has been my primary care doctor for 20 years.”

So she says she’s looking at other options, and she’s fortunate enough to have help from an insurance broker as she shops for a new plan.

Shore: “It’s enough to give you a migraine, truly.”

San Francisco based insurance broker Susan Shargel says she’s trying to sort out all the new ways insurers are contracting with doctors. Some health plans will have fewer doctors and hospitals. Blue Shield, for example will have half the doctors and three quarters of the hospitals they have this year. Shargel says the changes are not clear in the cancelation letters.

Shargel: “There isn’t something that says “Alert. Be aware. Take action now to be sure this works for you or to be sure you know what’s happening.” There needs to be a red alert.”

Health insurers say, it’s true, some plans will have fewer provider options next year. It’s happening on and off the exchanges. Patrick Johnston is from the California Association of Health Plans. He says the Affordable Care Act requires greater benefits to consumers in terms of coverage and out of pocket expenses. So one of the few cost variables to work with is doctor contracts.  

Johnston: “What’s left to control costs is the network, and in areas where there are a lot of hospitals, some more expensive than others, and a lot of doctors, it’s only natural that a health plan will sign up some, but maybe not all.”

So Johnston says if you’re buying your own insurance next year and want to keep your doctors, you may have to shop around.

Johnston: “Transitioning might mean looking or having difficulty signing up exactly the same doctors. But the benefits are rather enormous.”

Jerry Kominski is with the UCLA Center for Health Policy Research. He says insurers are negotiating for their bottom line.

Kominski: “We’re willing to pay you $50 a visit, just for example. If you’re not willing to do that, we know a doctor’s group across the street that will accept that.”

Kominski says the trend of narrowing provider networks to keep costs down is not new. But it’s been accelerating under the Affordable Care Act. It happens in group health plans too. 

Kominski: “What we have done in the last 30 years in the United States is moved more and more towards a market-oriented healthcare system…and markets depend on price competition.”

He says the jury is still out on whether limiting doctors in health insurance will affect quality of care. But he says there’s no question if affects choice.

Kominski: “If we want to keep healthcare from becoming completely unaffordable for everyone, at some point something has to give. And in this case what’s giving is the ability to choose any doctor and any hospital.”

Some plans may have a wide variety of doctors and hospitals, but you can expect to pay more for that choice.  

Related Content