The recent announcement that Covered California premiums will rise by double digits in 2017 — far higher than in previous years —— is only part of the challenge for the nation’s largest health exchange.
A newly released study found that 4.38 percent of Covered California policyholders enrolled in Blue Cross or Blue Shield plans were rejected by doctors supposedly accepting their insurance, compared with 1.41 percent for people with the same plans purchased outside of the exchange.
The report, published in this month’s issue of the journal Health Affairs, used secret shoppers to schedule appointments during summer 2015 with more than 700 randomly selected doctor offices in five regions of the state, including San Diego, the Central Valley and San Francisco.
Researchers wanted to find out whether patients on health-exchange plans would encounter different access to physicians, and they picked Anthem Blue Cross and Blue Shield of California because no other insurers in the program offer policies across the entire state.
The study took advantage of the fact that both carriers offer “mirrored” plans — those available both in and outside of Covered California. These plans are the same in all but one key aspect, said study co-author Simon Haeder, a political science professor at West Virginia University.
“The plans have slightly different names on and off the exchange, so it is possible for a doctor’s office to tell whether or not it’s a Covered California plan,” Haeder said.
The secret shoppers called doctor offices and requested appointments, trying once with a Covered California plan and a second time with its non-exchange counterpart. In all cases, the shoppers inquired with physicians who were listed in official directories as participating in their insurance plans.
The gap in access was starkest in San Diego County, where 8 percent of Covered California callers were told their insurance was not accepted — compared with 0.74 percent for plans sold outside the exchange.
James Scullary, a spokesman for Covered California, said he had no explanation for the difference in rejection rates.
“We’re looking into it,” he said.
The insurance companies also offered no explanation, though both said they are working hard to improve the accuracy of their doctor directories.
Haeder said his research did not determine why physicians seemed to be rejecting Covered California enrollees more frequently. Given that 90 percent of Covered California enrollees have an income-based government subsidy while those not in the exchange must pay full price, Haeder suspects the gap may be financially motivated.
“Maybe there is some sort of economic selection going on,” Haeder said.
He also said the problem likely extends beyond the Golden State.
“I think it’s probably representative of national insurers that do business on that kind of model,” Haeder said. “It would be hard to think that there are these massive problems in California and they have everything figured out in other states.”
Another significant point the secret shoppers discovered involves appointments in general: Regardless of their plan, they often had difficulty securing an appointment with their targeted doctor. More than 70 percent of the callers were unable to get a slot with their first-choice physician, even for weeks or months in advance.
The biggest reason for this failure rate: Doctors were frequently listed under the wrong specialties in the two Blue insurance directories. The problem was the worst in San Diego County, where 42 percent of calls were to doctors who had been miscategorized. Offices also regularly told secret shoppers they had no such doctor practicing there, didn’t pick up the phone or didn’t return messages.
Doctor directory inaccuracies first surfaced in 2014, the first year that Covered California plans were in effect due to the Affordable Care Act mandating that most Americans have health coverage or pay a tax penalty. When customers started complaining about difficulties using their new coverage, the exchange’s officials and insurance companies vowed to do better.
A year later, it appears the inaccuracies were still occurring.
The Health Affairs study notes: “The problem was identified and publicized by the State of California at the end of 2014, and yet by the summer of 2015, when this study was done, it seemed to have become more serious, with larger error rates than before.”
Faced with complaints from constituents and advocacy groups, state Legislators passed Senate Bill 137 in October. The bill requires all health plans to update their online directories weekly and printed copies quarterly. It also allows insurers to withhold payment to medical providers who don’t respond to directory information requests and holds carriers responsible for extra health costs incurred by patients who made medical decisions based on faulty directory information.
Both Blue Cross and Blue Shield said they have made “thousands” of updates to their directories since the secret shoppers did their survey last year.