Thousands of Sansum Patients Left Stranded

Covered California Getting Mixed Reviews

<b>SHORTCHANGED?</b> Dr. Scott Kozak said Covered California reimbursement rates for new patients are much lower than what he’s used to. “If I make 30 percent less than my fee schedule, it makes it impossible for me to give you care,” he explained.
Paul Wellman

Kurt Ransohoff may be the CEO of Sansum Clinic, the biggest health care provider on the South Coast, but he’s also a primary-care doctor trying to escort his own patients through the confounding maze of health-care reform. Even Ransohoff, schooled in the intricacies of bureaucratic esoterics, can’t believe how confusing it is.

For example, because of provisions in the Affordable Care Act, all patients who purchased health-care plans on their own must be transferred to one of the two health-care exchanges authorized to operate in Southern Santa Barbara County, Anthem Blue Cross or Blue Shield. But because Sansum and Blue Shield could not come to terms, as many as 2,000 Sansum patients who purchased individual Blue Shield policies have suddenly found themselves forced to find new health-care providers, effective January 1.

Many patients with long-term policies erroneously believe ​— ​because of exceptions written into the Affordable Care Act ​— ​that they can still seek medical treatment at Sansum. Ransohoff has one such patient whom he’s been treating for 15 years. “She’s a medical person,” he said. “She works in a hospital.” Ransohoff said he warned her that she may no longer be covered at Sansum. If she got treatment there, he cautioned, it would be vastly more expensive.

Sansum employees are spending an inordinate amount of time making the same case to countless other patients. But for Sansum patients who insist on seeing their longtime care providers rather than switching to Anthem Blue Cross ​— ​which, in fact, does cover Sansum ​— ​the real pain will arrive when the bills are mailed out and they experience serious sticker shock over how much higher their bills are. Jennifer Thomas, vice president of Sansum’s Revenue Cycle, said she dreads the time about a month from now when those chickens come home to roost. “We tell people in advance, and they say, ‘It’s just an office visit.’ But when the X-rays and tests are added in, it can be a lot more.” (The 1,000-2,000 affected patients, it should be noted, represent a small fraction of Sansum’s Blue Shield subscribers; most Blue Shield policyholders are employer endowed.)

Even the most cautious consumer could find herself sucked into the quicksand of insurance lingo, Ransohoff complained. He cited something called an off-exchange product. “It’s an exchange product that’s sold off the exchange. Can you imagine how confusing that is?” he exclaimed. It’s gotten so confusing, Ransohoff added, that many doctors in town don’t know whether they’re covered by the exchanges or not. He said the websites maintained by Anthem Blue Cross and Blue Shield are so misleading and confusing that the local medical association now maintains a site of its own to provide clarity.

Making a similar case is Dr. Scott Kozak, a 48-year-old primary-care doctor in a private practice. Kozak said he supported the Affordable Care Act because it was imperative something be done to address the 48 million people without any coverage at all. But the exchanges set up in Santa Barbara to implement these reforms, he said, do not pay doctors like him enough to accept the new patients. Typically, Kozak would be paid $120 for a patient’s first office visit. Under Covered California ​— ​the agency responsible for getting the Affordable Care Act off the ground in California ​— ​the reimbursement for such a visit is only $75.

Kozak said he turns away two to three people a day covered by one of the two exchanges, but he remains optimistic he can work something out with Anthem Blue Cross. In the meantime, Kozak said he’s hoping doctors and patients get mad enough that they’ll lobby the State Legislature to enact legislation giving the state Insurance Commissioner authority to regulate fee schedules with the health-care exchanges.

Not everyone, however, sees Covered California so negatively. Roger Perry, a well-known insurance broker in Santa Barbara, said the exchange plans are a great deal for families and individuals eligible for government subsidies. “I just sold a policy to a family of four that makes $48,000 a year; they’ll be paying $15 a month,” he said. “How else is a family that makes so little in Santa Barbara going to be able to afford health insurance?” He said he sold an employee of an avocado ranch with a wife and one child a similar policy for just $5 a month.

Perry was quick to acknowledge the excesses of the insurance companies, but he added that the difficulties between Sansum and Blue Shield might reflect the increasing centralization and monopolization of health care in Santa Barbara. Sansum and Cottage, he noted, are planning to merge soon, and Blue Shield might not be the only 800-pound gorilla in the room. “If we still had two and three hospitals like we used to, I tend to suspect there’d be more competition among the providers.” [Full disclosure: Perry is The Santa Barbara Independent’s insurance broker.]

Lindy Wagner, a spokesperson for Blue Shield, confirmed that the company requires doctors to accept a payment discount up to 30 percent, but said that in the exchange, Blue Shield provides medical professionals access to “an expanded patient population” of the newly insured. She added that the Blue Shield network complies with all access requirements imposed by the Department of Managed Health Care, adding, “We are confident that the network providers can meet the needs of our members.”

Editor’s Note: This story was revised on February 13, 2014, to clarify that it is Sansum and Blue Shield that have not been able to come to terms.


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