Anthem’s decision to pull out of insurance market fuels angst in Conejo Valley

Oct. 28--The decision by insurance giant Anthem Blue Cross to pull out of the individual insurance market is driving worries that some Conejo Valley residents could be forced to use a different hospital and possibly new doctors.

"I cried when I heard the news," said Kathleen MacAller, a Moorpark insurance agent. "I knew how bad it's going to be."

Anthem announced earlier this year that the financial instability in the market for plans offered through the Affordable Care Act was causing it to yank its plans in Ventura County and much of California beginning Jan. 1, 2018. It cited reasons including the uncertain future of the cost-sharing subsidies to insurers that have since been cut by President Donald Trump.

The decision means 9,630 Ventura County residents covered in Anthem plans through the Covered California exchange will have to switch to Blue Shield or Kaiser Permanente. People not covered by their employers and insured by Anthem in individual and family plans outside of Covered California will have to find new insurers, too.

Read more: States lose bid to restore Obamacare subsidies

The search triggers immediate anxiety because open enrollment in Covered California for next year starts Wednesday. Concerns are especially high in the Conejo Valley, where Anthem covered care at Los Robles Hospital & Medical Center in Thousand Oaks. But Kaiser, which operates its own hospitals, does not contract with Los Robles in its Covered California plans.

Blue Shield offers an HMO plan through Covered California, but almost all of its business in a three-county region that includes Ventura County came this year from its PPO plan.

That plan currently doesn't include in-network coverage at Los Robles.

People will still be covered at in-network rates for emergency care. They'll pay more for elective surgeries, births and other out-of-network care. MacAller worries that patients won't realize the impact of the changes until they try to schedule procedures and are told they have to find care farther from home.

"It's not going to hit them until it personally hits them, and then there's going to be an uproar," MacAller said. She is one of many pushing Blue Shield and Los Robles to come to terms.

Neither the hospital nor the insurer is saying much, declining to answer questions and issuing written statements that hint at barriers to a PPO contract.

"We recognize that expanding access requires negotiating an agreement that is favorable for both parties and we remain hopeful that we may be included in Blue Shield's network," said spokesman Adam Blackstone in the hospital's statement. "We are encouraging those that are insured by Blue Shield to communicate their desire to include Los Robles Hospital in their network."

Lauren Bartlett, of Blue Shield of California, said the insurer and the hospital have not had an individual and family PPO contract since Covered California was launched in 2014.

"Health care is local and costs are an important consideration in contracting with providers," she wrote in a statement. "We are open to having discussions with Los Robles Hospital & Medical Center as we are with healthcare providers throughout the state who share our goal to help ensure Californians have access to high-quality care at an affordable price."

The lack of a pact has stoked concern throughout the medical and insurance communities.

Many of the doctors at Arroyo Oaks Medical Group in Thousand Oaks who didn't previously contract with Blue Shield are now reaching out to the insurer. Because the insurer requires doctors have access to an in-network hospital, they're requesting staff privileges at Adventist Health Simi Valley.

Dr. Ronald De La Pena, of Thousand Oaks, says his options are limited. The obstetrician-gynecologist delivers only at Los Robles. If his patients lose their access to the hospital, he won't be able to care for them any longer.

"We're in the middle of this, like a lot of companies," he said, adding that the path to a resolution seems obvious.

"If Los Robles and Blue Shield would come to an agreement, that would be one way to bridge this problem," he said.

Roger Hayek, a Newbury Park insurance agent, is covered by Anthem but will have to switch. He said one option is a Blue Shield family plan that would cost $1,276 a month for him, his wife and two children -- about $250 more than his current premiums.

"That's a 25 percent increase," he said, noting that an out-of-pocket spending maximum for individuals is set at $20,000 by Blue Shield for Los Robles and other out-of-network providers. "It's almost like not like having coverage at all."

Hayek and MacAller both worry that patients may have to drive out of the Conejo Valley to find doctors who take Blue Shield PPO plans.

Dr. Ken Saul, a Thousand Oaks pediatrician, doesn't accept Blue Shield individual plan coverage because of the reimbursement rates. He is being approached by patients who were on Anthem and don't want to lose access to him or to Los Robles. So he is reaching out to Blue Shield.

"I've made a pledge to the patients that if it's at all a reasonable contract, I'll take it," he said.

Catherine Pedrosa, of United Way of Ventura County, is outreach and education specialist for Covered California plans. She said she's heard few concerns about Blue Shield and Los Robles.

"For most people, as long as their doctors are in the network, they feel comfortable with that," she said.

Tracy Severt isn't worried about Los Robles. She's worried about being abandoned. The self-employed Ojai woman has been covered by Anthem in a family plan for 20 years. She fears other insurance companies will follow Anthem's lead and drop out of the market. Or, she said, they could charge her far more for insurance.

She filed a complaint with Anthem and also targeted the insurer in a complaint filed with the California Department of Managed Health Care.

"I just feel it's not morally right," she said of Anthem pulling its plans, then offering another reason for her concerns. "I don't like change."

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