PAMF physicians missing from Covered California due to dispute with Anthem

Dec. 06--SANTA CRUZ -- Santa Cruz County residents searching for doctors with the Palo Alto Medical Foundation on the Covered California website will come up empty.

It's not a glitch with Covered California, which in fact has created an online physician directory, something Peter Lee, who runs the health exchange, said is helpful but rare.

"This is one of those December impasses," said Dr. Larry deGhetaldi, who heads the Palo Alto Medical Foundation Santa Cruz and Sutter Santa Cruz, noting all of Sutter Health is affected. "We really expect these contracts to be resolved by Dec. 31."

The impasse may be one reason enrollment in Covered California plans by Santa Cruz County residents is low.

A total of 668 people in the Monterey Coast region, which includes Santa Cruz, Monterey and San Benito counties, enrolled as of Oct. 31 out of 2,411 who applied and are eligible to buy.

Of those who did enroll, 71 are eligible for a subsidy.

Individual county data are not available, according to Covered California.

Capitola resident Mark Battey was surprised to get a letter saying his family would be assigned a new primary care physician and medical group because Sutter's contract with Anthem Blue Cross will expire Jan. 1.

"This is going to be a huge issue in Santa Cruz County with PAMF being a major local heath care provider and Anthem Blue Cross having a large market share here," he said.

DeGhetaldi said the state requires those letters be sent when an agreement is not reached 60 days before the old one expires.

"It freaks patients out," he said. "We've had a little over 500 calls."

Anthem is negotiating with Sutter, Anthem spokesman Darrel Ng confirmed.

Sutter is "one of a very few providers with clauses that don't allow us to reveal line-item pricing data to Covered California," he said. Sutter hospital prices were highlighted Tuesday in a New York Times report that cited a case where three stitches cost $2,200 at Sutter's California Pacific Medical Center.

Ng suggested people who do not find their doctors listed by Covered California call the doctors to ask if they are in the network.

PAMF doctors are in the Blue Shield plan, which is the least expensive, but DeGhetaldi was surprised that plan omits three ZIP codes, Boulder Creek, Davenport and the Los Gatos Summit.

Blue Shield spokeswoman Lindy Wagner said this is due to a state Department of Managed Healthcare requirement.

"If a ZIP code is only partially within the 15-mile radius area from a network hospital, then the DMHC requirement cannot be met for that ZIP code and the entire ZIP code must be excluded," she said.

Lee said nearly 80,000 people have picked an insurance plan on Covered California and 50 percent were eligible for a subsidy.

Asked about difficulties insurance agents had with CoveredCa.com, Lee said the focus was on readying the website for consumers by Oct. 1, with agent functions added after that date. In Santa Cruz County, 82 agents are certified by Covered California.

Santa Cruz County also has 30 certified enrollment counselors working with Community Bridges, Encompass Community Services, Firm Revenue Cycle Management Services, Pajaro Valley Unified School District, Salud Para La Gente, Santa Cruz Women'sHealth Center and United Way of Santa Cruz County.

Follow Sentinel reporter Jondi Gumz at Twitter.com/jondigumz

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