It's debatable if the fiduciary standard is 'higher' than suitability. But the better question might be, who's holding the bar?
Oct. 27--As New Mexico's third largest health insurance company and the state's largest medical group contentiously end their five-year-old contract, thousands of confused and angry customers are left to choose sides.
When Lovelace Health Plan stops paying for care given to most patients of ABQ Health Partners on Nov. 8, many people will have to decide which relationship they value more: with their doctors or their health insurance company.
"To me, this is incredible," said Esteban Rael, who has been trying to understand the choices available to his 95-year-old grandmother, Mabel Thomas.
"She's got 50 years of medical records and people who know her," Rael said. "The doctors talk to each other and know her. How would you be able to rebuild rapport in a short period of time? It's unfathomable that we live in a time when you can just be shoved off."
Thomas has had Lovelace insurance since the 1970s. ABQ Health Partners, which has 184 physicians, was formed from Lovelace's old medical group, and she has been a patient of Lovelace since 1957.
Some plan members actually won't have a choice and will be forced to change physicians. Their employers signed Lovelace contracts that don't expire until next year. Forced to change doctors
Each company has argued its case in full-page newspaper advertising.
Both have sent letters to customers' homes encouraging them to abandon the other. Lovelace has sponsored town hall-style meetings for members.
Telephone operators for both sides are fielding calls.
The state Insurance Division, which regulates Lovelace, has received hundreds of calls from worried and confused customers.
Lovelace says it has more than 210,000 members statewide and has 9,000 health care providers in New Mexico on its insurance panels, including 4,000 in the Albuquerque area.
Two ABQ Health Partners employees recently staffed a table in the lobby of the practice's Journal Center clinic, passing out a list of the insurance plans the practice accepts.
A Lovelace employee sat in the company's pharmacy off the ABQ Health Partners clinic lobby explaining to members how to change doctors.
Sandra Humphries is a Lovelace Senior Plan member. "I adore my doctor," she said. "Why should I have to switch?"
She called some of the insurers that ABQ Health Partners still accepts. One doesn't offer a Medicare Advantage plan. One was sending information by mail, and a third didn't answer its phone, she said.
"There are really only two choices, Blue Cross and Amerigroup," Humphries said. "But Blue Cross doesn't offer Silver Sneakers," which is a fitness program some local Medicare Advantage plans provide.
Greg Becwar, a U.S. West retiree, emerged from the Lovelace pharmacy committed to staying with the health plan.
"The letter I got in the mail was confusing," he said. "I got on the phone, and it was more confusing." The chat in the pharmacy clarified things.
"If we stay with Lovelace the doctors change but everything else stays the same," he said. "Doctors change all the time anyway. It's no big issue to us. All in all, it's a simple maneuver. We're close to 80. We can take the change."
Patrick Hoffman is a Sandia National Laboratories retiree, one of 900 Sandia retirees and their spouses, out of 7,200 Sandia retirement health care beneficiaries in total, who are covered by a Lovelace Medicare plan.
The dispute coincides with Sandia's open enrollment period during which retirees are choosing the retiree health benefit they will take for the coming year. There are several choices.
Sandia senior health benefits manager Mary Romero Hart said retirees and spouses can stay with Lovelace, move to Presbyterian Healthcare Services insurance, or take "health care dollars" that can be used to buy their own Medicare Advantage or Medigap insurance.
"Sandia currently has Medicare retirees enrolled in more than 300 individual Medicare plans nationwide through Extend Health and Extend Health currently offers nine Medigap plans in Albuquerque that includes ABQ Health Partners clinicians," Hart said.
Extend Health is the company Sandia uses to administer the benefit.
Presbyterian Health Plan, the state's largest insurer, is not an option for those wishing to keep ABQ Health Partners.
Presbyterian does not contract with the practice.
No longer 'seamless'
For Hoffman, the Lovelace-ABQ Health Partners relationship had always been "seamless. I didn't know who owned what. I'm finding out now that this facility is ABQ Health Partners'. I thought it was a Lovelace facility."
The clinic offered one-stop shopping, he said. Almost any medical service he needed was in one building.
"I called Lovelace for a new primary care provider," Hoffman said. "It's been very frustrating."
Hoffman said his calls aren't returned, the company's website lists providers who aren't taking new patients, and other providers have long waits before appointments can be made.
"There is no telling when I'll see a doctor," Hoffman said.
Dan Cobb is a retired journalist who uses ABQ Health Partners for cardiac care.
In a phone interview he said, "I called them to see what the situation was and they told me anything Lovelace won't cover (before he can change insurance plans), they'll just eat it. ABQ Health Partners went up a few notches in my estimation after they said that."
In another lobby, at Lovelace's Heart Hospital near Downtown Albuquerque, several dozen health care providers, insurance brokers and health plan members gathered to show their support for Lovelace.
"These providers are gathered here to show their support for their patients in New Mexico and the members of the Lovelace Health Plan," said Robert Federici, a cardiologist with New Mexico Heart Institute who is on the Heart Hospital Staff. "What we like about Lovelace Health Plan is its leadership," who, he said, are "almost all doctors. They know what it is like to take care of patients."
Philip Briggs, a physician and founder of Atrinea Health LLC, said he is "committed to working with Lovelace Health Plan" and is expanding his practice to accommodate patients who need to move from ABQ Health Partners. "We're getting a lot of calls to schedule patients already," he said.
Lovelace also recently bought Southwest Medical Associates, a 34-provider medical practice.
Ray Horcacitas is a 75-year-old trainer at the YMCA. "I believe in the family of Lovelace," he said. "I'm proud to be a Lovelace family member." He has been with Lovelace for 37 years.
"I've had to change my primary care doctor, which is a little bit hard, but it's nothing to cry about," Horcacitas said. "He is going to be my friend for life. It's not hard to change." Transition care
Lovelace and ABQ Health Partners have identified about 3,000 patients who are in the middle of a course of treatment, scheduled for surgery or recently released from a hospital or nursing home. These patients don't have to choose until their medical care is completed. ABQ Health Partners has said it will continue to care for Lovelace plan members through the end of the year so Medicare Advantage plan members in particular see no gap in coverage before their new insurance plan contract periods begin.
(c)2012 the Albuquerque Journal (Albuquerque, N.M.)
Visit the Albuquerque Journal (Albuquerque, N.M.) at www.abqjournal.com
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