Covered California clients have trouble finding doctors

Sue Kearney of Oakland, who bought a policy from Anthem Blue Cross through Covered California, has had trouble finding a doctor who will accept her plan. Sue Kearney of Oakland, who bought a policy from Anthem Blue Cross through Covered California, has had trouble finding a doctor who will accept her plan. Photo: Michael Macor, The Chronicle Photo: Michael Macor, The Chronicle Image 1 of / 4 Caption Close Covered California clients have trouble finding doctors 1 / 4 Back to Gallery

Think signing up for health insurance through Covered California is hard? Some consumers say the real battle starts when it comes to finding a doctor or hospital that will take a plan purchased through the state-run health exchange.

Sue Kearney of Oakland thought she did her homework. She found the policy she thought was right for her - one from Anthem Blue Cross - and checked the plan's directory of doctors and hospitals to make sure she could get the specialist she wanted. Assured of that, she signed up for the plan in October.

But right before a doctor appointment this month, Kearney learned the physician's medical group will not accept any of Covered California plans.

Kearney, 63, who has a chronic digestive problem that hasn't responded to treatment, ended up paying $200 for the appointment, despite her newly minted coverage. "It's confusing and demoralizing," she said.

Most of the problems with the new health system have focused on online application glitches, long wait times to get help and delays in getting insurance cards and first-month premium bills to new enrollees.

'A lot of confusion'

But now that coverage has started, some people are finding it tough to determine whether their doctor or hospital will accept their coverage. Consumers say the insurer's directory of doctors and hospitals is inaccurate or out of date. In some cases, the doctors don't even know what to tell their patients.

"There's a lot of confusion. The physicians don't know if they're actually participating" in the exchange's networks, said Donald Waters, executive director of the Alameda-Contra Costa Medical Association, which represents 3,100 doctors in the East Bay.

The problem is not limited to California. A study released last month by the consulting group McKinsey found that many plans sold through the federal health law are using "narrow" or "ultra narrow" networks - physician and hospital lists that are limited to lower costs.

In more than two-thirds of all exchange networks analyzed by McKinsey, at least 30 percent of the largest 20 local hospitals were excluded. Insurers say the move to limit the number of doctors and hospitals on a network was necessary to keep the costs of premiums low.

In California, plans offered by Blue Shield through Covered California included just 60 percent of the doctors that participate in the insurer's group plans and just 75 percent of the hospitals. On top of that, Blue Shield is reimbursing doctors and hospitals in Covered California policies up to 30 percent less than those not in the exchange, spokesman Stephen Shivinsky said.

Limited networks

Sy Neilson, spokesman for Sutter Health, one of Northern California's largest health chains, said not all of its hospitals or doctors are participating in Covered California plans. But the hospitals and doctors that are participating are involved in limited networks, he said.

Anthem officials did not respond to requests for comment.

For his part, Peter Lee, Covered California's executive director, acknowledged that consumers may be getting misinformation from the state agency or insurer about whether their providers are participating. But, he said, the exchange is prepared to help those consumers get new plans that more suitably meet their needs.

"If our directory or the directory of the health plan is wrong and a consumer wants to change plans, we'll work with them to make sure they can do so," Lee said in a news call this week.

As for Kearney, she spent much of the past week trying to find a gastroenterologist and a lab to complete the tests ordered by the specialist she paid for. She said Alameda Health System's Highland Hospital - the county hospital - was the only center in her area that would take her, and not until March.

Kearney had even opted for more comprehensive coverage including a PPO, or preferred provider organization plan. "I chose a PPO so I could have had choice," she said. "The thing is, now I have nothing to choose from."

For Alison Berndt of Livermore, making sure her physicians were in her new plan's network is especially important because she was diagnosed with breast cancer in July.

Berndt, 61, selected a more expensive Covered California plan to ensure her five doctors, particularly her plastic surgeon, were in the network because she has yet to go through the reconstructive surgery.

Cutting medications

After she signed up, she called one of the doctors she thought was included on her Anthem policy and received conflicting information from the office staff about whether that was true. She spent a lot of time on the phone and eventually learned she was given misinformation and they were, indeed, accepting her coverage.

Berndt still hasn't been able to sort out a problem getting her drugs covered and has been forced to cut her blood pressure and cholesterol medication in half.

"Every step of the way has been crazy," she said.