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Health Insurance & Affordable Care Act

Specialty Care Is A Challenge In Some ACA Plans

WebMD News from Kaiser Health News

By Carrie Feibel, Houston Public Media

Wed, Jul 16 2014

Primary care doctors have reported problems making referrals for patients who have purchased some of the cheaper plans from the federal insurance marketplace. Complaints about narrow networks with too few doctors have attracted the attention of federal regulators and have even prompted lawsuits.

But they’re also causing headaches in the day-to-day work of doctors and clinics. “The biggest problem we’ve run into is figuring out what specialists take a lot of these plans,” said Dr. Charu Sawhney of Houston.

Sawhney is an internist at the Hope Clinic, a federally qualified health center in southwest Houston, in the bustling heart of the Asian immigrant community. Her patients speak 14 different languages, and many of them are immigrants or refugees from places as far flung as Burma and Bhutan. Most of her patients are uninsured, which means she is familiar with problems of access.

But the limited options of some of the HMOs sold on the marketplace surprised even her.

“I was so consumed with just getting people to sign up,” she said, “I didn’t take the next step to say ‘Oh by the way, when you sign up, make sure you sign up for the right plan.’”

Understandably, a lot of Sawhney’s patients picked lower-cost plans, “and we’re running into problems with coverage in the same way we were when they were uninsured.”

One of her patients is a Chinese immigrant who purchased a Blue Cross Blue Shield HMO silver plan, and soon after was diagnosed with stomach cancer.  Sawhney found a Mandarin-speaking oncologist who participated in the plan, but she and the oncologist soon ran into trouble trying to schedule treatments. “The process just isn’t as easy as we thought it would be,” she says.

It was tough to find participating Houston hospitals and doctors. The two largest hospital chains in Houston, Houston Methodist and Memorial Hermann, are not in that plan’s network. Neither is Houston’s premier cancer hospital, MD Anderson Cancer Center.

Those are precisely the hospitals that the patient’s oncologist, Dr. Paul Zhang, calls on the most. He says coordinating surgery or radiation usually isn’t a problem, because most of his patients have insurance plans with wide networks.

“I could not find a surgeon,” Zhang said. When he finally found a surgeon who actually took the insurance, it wasn’t someone he had ever worked with before. He said he would have preferred a surgeon who specialized primarily in cancer, because the patient’s cancer was complicated and had spread to 30 lymph nodes.

“You have limited options,” he said of the patients in the HMO. “So you’re like a second-class citizen, you know? That’s my feeling, you have this insurance and you cannot see certain doctors.”

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