Managed care is alive and sick
Doctors object to ultimatum on health care
By Cheryl Clark
The San Diego Union-Tribune
February 26, 2006
Dozens of doctors are protesting a Sharp physician network’s demand that their senior patients enroll in one health plan, Secure Horizons, if they want to use Sharp’s services in San Diego County.
Some 22,000 patients could be caught in the cross hairs, the doctors said.
These 45 doctors have until Tuesday to accept or reject Sharp’s ultimatum. If the physicians decide to work exclusively with Sharp, their non-Secure Horizons patients must switch to Secure Horizons or find primary-care doctors who accept their current health plan by June 1.
If the independent doctors contract exclusively with Sharp, community hospitals such as the 301-bed Paradise Valley Hospital also would suffer.
Dr. Alan Schoengold, Sharp Community Medical Group’s president, said his network “is very well aware of the ramifications” for patients, hospitals and physicians.
For doctors who face financial difficulties because they gave up non-Secure Horizons patients, Sharp will advance payment and provide loans to them.
No matter what the dissenting doctors choose, they will lose some patients. If they select Sharp, they will lose patients who want to stay with Health Net or other providers. If they opt to remain independent, they will lose their Secure Horizons patients to Sharp.
Lincoln Acres resident Ruth Wells, 87, said she recently switched from Blue Cross to Health Net, whose network includes her specialists and whose pharmacy plan covers the drugs she needs.
But when Wells was told that her physician may require her to switch to Secure Horizons, she became very upset.
“It’s not fair,” she said. “I want to see doctors in my neighborhood.”
http://www.signonsandiego.com/uniontrib/20060226/
news_1m26sharp.html
And…
Blue Cross Coverage Extended in Dispute
By Lisa Girion
Los Angeles Times
February 25, 2006
State regulators stepped in Friday to delay a showdown that threatens access for more than 175,000 Blue Cross members to three hospitals in Los Angeles County.
The state Department of Managed Health Care intervened in a long-running fee dispute that pits struggling hospital operator Centinela Freeman HealthSystem against the nation’s largest insurer, WellPoint Inc.
Centinela Freeman Chief Executive Mike Rembis said the company had hoped to go into the black this year. But, he said, that hinged on getting an adequate increase in reimbursements from Blue Cross.
Almost a quarter of Centinela Freeman patients are Blue Cross members but they provide only 9% of revenue, administrators said.
Blue Cross has asked the Department of Managed Health Care for permission to send its members to other hospitals in the event that they fail to reach a new agreement. Blue Cross members also could use Centinela Freeman hospitals but would be reimbursed at a lower, out-of-network rate.
http://www.latimes.com/business/la-fi-centinela25feb25,1,3558558.story
Comment: By Don McCanne, M.D.
Those who claim that the age of managed care is ending simply haven’t been paying attention.
Health care intermediaries continue to leverage their positions by taking choice away from patients, physicians and hospitals. Periodic contract changes create instability, negatively impacting patients’ choice of physicians and hospitals, while threatening the solvency of the providers.
The consumer-directed (CDHC) advocates claim that their model would replace managed care. But the high-deductible health plans (HDHPs) that they are touting are still managed-care preferred provider organizations (PPOs). Though these plans may allow out-of-network health care, the patients’ out-of-pocket expenses are so great that it is almost equivalent to having no coverage at all.
Adopting a single payer national health insurance system would return to patients free choice of health care providers, including the option of choosing integrated health systems such as Kaiser Permanente. The CDHC advocates want patients to participate in their health care decisions. They should start by giving them choice of their physicians and hospitals. That will never happen with PPO HDHPs which, by design, deliberately restrict choices.