PAMF deals with Blue Shield, Health Net come too late for some

Jan. 07--SANTA CRUZ -- For the past month, Santa Cruz County residents with Blue Shield or Health Net health insurance covering 250 doctors at Palo Alto Medical Foundation Santa Cruz were in limbo because the two insurers had no agreements with those physicians for 2017.

"We couldn't give advice to our clients," said Doak Gintert, who owns Santa Cruz Health and Life. "It was very frustrating."

Sutter Health, parent of Palo Alto Medical Foundation, came to a one-year agreement with Health Net on Dec. 30 and announced a three-year agreement with Blue Shield on Wednesday, four days into the new year.

"I'm tired of changing doctors," said Stacie Clary, a career coach in Capitola.

Two years ago, she switched to Anthem from Blue Shield, frustrated by the insurer's delays in reaching an agreement with the physicians, and she got a doctor she liked. But when Anthem said her premium would go up $300 a month in 2017, she switched to Kaiser Permanente.

"I'm healthy," she said. "I can't justify spending the money."

Santa Cruz resident Kathy Duncan said she and her husband are switching to doctors at Dignity Health Dominican.

Dominican physicians accept the Health Net exclusive provider plan offered through Covered California, she said, and Sutter Health does not.

Duncan found the cost, worse case scenario, for her family would be $1,864 a month plus $13,600 out of pocket totaling $34,000 a year for the Health Net bronze preferred provider plan -- with no subsidy for a couple earning more than $64,000.

"If we earned $65,000, that would leave us $31,000 a year for all our other expenses," she said.

For 150 postdoctoral researchers at UC Santa Cruz and thousands more at other UC campuses, a new contract with the university in October with coverage by Health Net was cause for celebration.

"A lot of them use Sutter Health facilities," said Neal Sweeney, active in negotiations as vice president of the United Auto Workers 5810. "We didn't know a lot of doctors could have been cut off."

The union learned in late November that Sutter Health access was threatened, gathered 1,500 signatures including some from retirees via online petition, and met Dec. 15 with the graduate dean to ask university leaders to use their leverage with Health Net to encourage an agreement.

"The university is one of their biggest customers," Sweeney said, noting some high-ranking administrators thanked union leaders for alerting them to the issue.

Switching to Kaiser Permanente was not an option, he said, because Kaiser is not available in Santa Barbara to serve the UC researchers.

"We have some clients switching to Kaiser," said Gintert, but he said most did to want to give up the Palo Alto Medical doctors they had grown up with.

Born and raised in Santa Cruz and living on the Westside, Gintert was among them, reluctant to switch to Kaiser, which is sending Santa Cruz County members to Watsonville Community Hospital.

"We're used to going up to Stanford (Hospital)," he said. "With Kaiser, there is no out of network."

For Pamela Fugitt-Hetrick of DCD Financial & Insurance in Santa Cruz, the trend was different.

"More than half, maybe three-quarters of my clients switched," she said.

People with chronic conditions, those taking medications monitored by specialists or dealing with mental health issues were willing to pay more to keep their doctor, $100 a month for and individual and $400 a month for a family.

"Is it worth it $1,200 a year to see them?" she asked clients. "They would roll their eyes and say 'No.'"

By the time Health Net and Sutter Health came to terms Dec. 30, it was too late for consumers to buy coverage for Jan. 1. Their plan would take effect Feb. 1.

Duncan bemoaned the failure of insurers and medical providers to get in sync with Covered California's deadlines.

"Why does everyone need to decide on a health insurance plan by Dec. 15, but these providers and insurers don't have to resolve until into the new year?" she asked.

Sweeney said it would make sense for plans to expire June 30 rather than Dec. 31 in the middle of the holidays.

"There's no requirement they have to sign," said Fugitt-Hetrick. "If you're waiting for it to make sense, let it go."

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