Obamacare Odysseys

Patients With Low-Cost Insurance Struggle To Find Hospitals and Specialists

“Narrow network” plans mean fewer choices in exchange for lower premiums

The Affordable Care Act created a whole new pool of individual health plans, and these were sold through the healthcare.gov website. Shoppers in the Houston region could choose from 42 different plans.  

Some plans had higher premiums, but came with lower deductibles, or offered access to more hospitals.

And some plans had lower premiums  – but had higher deductibles, and fewer choices when it came to hospitals and doctors. These plans are typically called “narrow network” plans.

Nearly 200,000 Houstonians signed up. Dr. Charu Sahwney, an internist, said many of her uninsured patients naturally gravitated toward the cheaper plans.

“They’re excited because they have insurance, they have coverage and I feel like they’re just going to get disappointed, that coverage is not what they thought,” she said.

The disappointment comes when patients learn the cheaper options, usually HMO plans, don’t include all the hospitals in Houston. And many specialists don’t accept them either.

Sahwney had a patient who was diagnosed with stomach cancer, soon after purchasing an HMO plan on the website. She then realized the patient could not be treated at MD Anderson Cancer Center, Houston Methodist, or Memorial Hermann. None of those hospital systems accept that insurance.

But the biggest surprise for Sawhney was that she couldn’t even send the patient to the public, safety-net hospital system, Harris Health, where uninsured patients typically go for treatment. Harris Health wasn’t taking the plan either.

“It’s been really surprising to me that the network with the HMO plan has been so limiting that I’ve had better luck finding care for my uninsured patients than I have had with my patients with Blue Cross Blue Shield HMO,” Sahwney added.

A spokesman for Harris Health says it wanted to participate in all the new plans, but the reimbursement rate offered by the Blue Cross HMO plans was too low. He said they are currently negotiating to participate in those plans for 2015.   

Louis Adams is with Blue Cross Blue Shield of Texas. He says consumers can choose among a range of prices and options.

“We created more focused networks as a way to offer a broad range of plans with lower premium prices, both on the exchange and the retail market in general,” Adams said.

Federal regulators are paying attention to the problem. They’ve already told insurance companies that plans for 2015 must have an adequate number of specialists and hospitals. For example, a plan can’t require a patient to drive hundreds of miles to see a specialist. Or wait months for an appointment.

Dr. Sawhney eventually found doctors who took her patient’s plan. After many phone calls – and consultation with an oncologist – the patient got surgery, and is now undergoing radiation and chemotherapy treatment.

The patient spoke about the experience through a Mandarin translator. He asked not to be identified because he hasn’t told many people he even has stomach cancer.

He said the whole experience turned him off to Obamacare.

“If that insurance (is) like that,  maybe I will talk to all the people: ‘Don’t buy the insurance.’ Because nobody wants (to) accept the insurance.”

Sawhney said she’s worried that other patients may decide the new insurance is simply not worth the money.

“I don’t want patients to get discouraged, I don’t want patients when they have a choice again to say ‘You know what? I’m just not going to sign up because it doesn’t matter if I have insurance or I don’t have insurance, I still have problems getting health care,’” she said.

But despite the delays and difficulties, Sawhney said she still believes it’s better to have insurance, and she still believes in the law.

“I want this to work,” Sawhney said. “The health care exchanges make sense to me, but when the networks are so limiting, I’m not certain how it’s going to pan out over the next couple of years. I think these networks need to change for this to be a reasonable solution to our healthcare issues.”

Next year, Sawhney will tell her patients to shop for insurance more carefully: taking into account not just price, but whether they want to see certain specialists, or need access to a particular hospital.

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Dr. Charu Sawhney examines patient Mang Caan at the Hope Clinic in southwest Houston. Sawhney supports the Affordable Care Act, but has been frustrated by how difficult it is to find specialists who accept some of the plans her patients bought.

 

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