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Tuesday, May 20 2014 03:00 AM

ASK EMILY: Network nightmares: When your doctor and hospital don't mix

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BY EMILY BAZAR, Center for Health Reporting

What good is it to have a health plan if you can't find doctors and hospitals to accept it?

That question rushes to mind every time a frustrated reader writes in to describe his or her Kafkaesque quest to find care.

I'm also hearing from frustrated medical providers, including Dr. Nelson Branco, a pediatrician in Marin County.

Branco was one of more than 2,300 California doctors who participated in a survey conducted by the California Medical Association (CMA) in April.

The survey found that 80 percent of those who responded were, at some point, confused about their participation in health plans sold by Covered California, the state's health insurance exchange.

That was "at some point." Right now? One in five doctors remains confused.

Poor consumers! What chance do you have to find a doctor in your network if doctors themselves don't know?

In today's column, I'm sorry to have to describe yet another pitfall that could complicate your ability to receive care from a doctor who participates in your health plan.

Q: I bought a Blue Shield plan, which my physician is on. But the only hospital where my doctor has privileges is not contracted with Blue Shield. Is this problematic?

As a matter of fact, yes.

Let's say you need surgery.

Your doctor, who is in your network, plans to perform the procedure at a nearby hospital, the only hospital where she has privileges.

You do a little homework (because that's what you have to do in this new insurance environment), and you discover that the hospital isn't in your plan's network.

Uh-oh.

As more Californians start to use their new health insurance, they're finding these kinds of doctor and hospital mismatches: Sure, there may be hospitals in your network. But they're not necessarily the ones to which your physician can admit patients.

These mismatches often are a result of newly created "narrow networks" that have limited doctor and hospital choices for plans bought through Covered California or on the private market.

These networks were created by some health insurance plans to save money: Insurers pay fewer providers lower fees but promise them higher volumes of patients in return.

(Not that networks were unlimited before. But now, some are substantially smaller.)

In Marin County, when children need urgent care in the evening or on weekends, the county's pediatricians refer them to a specific after-hours clinic, Dr. Branco says.

But Branco's patients who purchased an Anthem Blue Cross plan through Covered California can't get in-network coverage at the clinic. Even though Branco contracts with Anthem, the clinic does not.

Faced with the prospect of paying out of pocket, some parents simply take their children to the emergency room, a much more costly form of health care, he says. (And one that defeats two major goals of Obamacare: Reducing unnecessary care and lowering costs.)

"It's really a mess," the pediatrician says. "The after-hours clinic has kept thousands of patients out of the ER and saved thousands of untold ER dollars. Now, to limit access to the after-hours clinic is really just shooting ourselves in the foot."

Hospitals are complaining about mismatches, too, says Dietmar Grellmann of the California Hospital Association.

"If a health plan throws networks together and doesn't take the time to sort through the physician admitting relationships (with hospitals), you get these kind of mismatches," he says.

Lindy Wagner of Blue Shield of California says mismatches shouldn't occur because the networks "were designed to include physicians with admitting privileges to hospitals in the network."

Blue Shield is working with doctors to clear up confusion about their participation in plans and is continually adding doctors to its network, she says.

That's all great. But it is happening.

What are consumers to do now?

The most critical time to do your homework on networks is before you buy a plan, Grellmann says.

"When consumers sign up for Covered California, they really need to do some due diligence, not just shop for the cheapest product," he says. "The days of signing up for a plan and expecting everything to go great are probably over."

Grellmann acknowledges that confusion and misinformation reigned during open enrollment, and that it was very difficult for consumers to decipher networks at that time.

So now that you're stuck with a plan, the best thing you can do is verify, verify, verify.

Confirm not only that your doctor is in network, but the hospital, too. Check your information against multiple sources, including your insurer.

And get nosy.

"It may be worth asking your doctor if they have privileges at a network hospital," says Brett Johnson of the CMA.

If you learn that the hospital or hospitals where your doctor has privileges are NOT in your network, you likely face an unpleasant reality (assuming you don't want to be out tens of thousands of dollars for going out of network): Switching doctors.

"They're going to have to make a choice that, from the patient's perspective, is probably not a good choice," Grellmann says.

Questions for Emily: AskEmily@usc.edu

The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.

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