What can be done about Covered California's doctor gap?

Consumers are misled too often on which doctors accept subsidized plans sold through Covered California

The insurance reforms in the 2010 federal healthcare law went into full effect this year, dramatically reducing the number of Californians who don't have health coverage. At the same time, however, some low- and moderate-income residents have struggled to find doctors who'll take their insurance. Their complaints are forcing state officials to investigate the accuracy and adequacy of insurers' networks of medical providers. Though the attention is welcome and overdue, what's really needed is a better approach to consumer protection.

The healthcare law expanded coverage in two ways, allowing states to make more impoverished Americans eligible for Medicaid and providing premium subsidies for those with somewhat higher incomes. Those provisions went into effect Jan. 1, and it's too early to tell whether the number of physicians in the state is expanding fast enough to meet the need, particularly for primary care. What is already clear, however, is that consumers are being misled too often about which doctors accept the subsidized plans sold through Covered California, the state's new insurance exchange.

The best illustration of this comes from Humboldt County, where a recent survey found mistakes in two-thirds of the listings for family doctors that Anthem Blue Cross claimed were in the network serving its Covered California policyholders. Most of the doctors on this list weren't taking new patients, and many weren't providing primary care period. A separate study of three rural counties by the California Health Report found that more than half of the doctors listed by Medi-Cal in those counties either were turning away new patients or couldn't be reached by phone.

The lists that insurers gave Covered California were riddled with errors too, causing the exchange to pull the plug in February on the provider directory it had set up for online insurance shoppers. It will not have a replacement in time for this year's open enrollment period.

Inaccurate provider directories have plagued the industry for some time, reflecting the complex and ever-changing web of insurance plans and provider groups. The problem became more acute this year, though, as many people who'd previously been covered switched to new Covered California plans with more restricted choices of doctors and hospitals. There's nothing inherently wrong with such "narrow" networks; in fact, they can help control costs and improve quality. But consumers should be able to find out who's available to treat them before they sign up for a plan.

The fact that they haven't been stems in part from alarmingly poor communication between doctors and insurers, and the lack of incentive to keep provider lists accurate. Considering how closely they work together on billing, it's grating that insurers can't keep up-to-date lists of the doctors whose work they finance. But there's also some evidence of insurers exaggerating the breadth of their networks for the sake of attracting customers. In addition, there are doctors who either misunderstood or ignored contracts that allowed insurers to assign them to plans serving Covered California customers without their prior approval.

A related issue is whether the networks offered by health plans can actually deliver the coverage the plans promise. State law sets standards for provider networks governing such things as wait times and travel distances for appointments. But a better approach would incorporate the new measures being developed in the industry to track how effectively and efficiently providers deliver care, so that the adequacy of a network wouldn't be judged just by its size.

More fundamentally, the judgments made about a network's adequacy are meaningless without an accurate picture of which providers are in it. Insurers say they're taking the problem seriously, which should help both those who shop for individual policies and the growing ranks enrolled in managed-care plans through Medi-Cal. Ultimately, the solution for both groups is the same: developing an automated way to update provider lists to track the changes in doctors' locations, plan affiliations and ability to accept new patients. Regulators should work with insurers and providers to come up with such a mechanism, along with a better incentive to end the errors.

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