Covered California will be adding two elements to the health plans sold through their marketplace exchange in 2017. The first is a new ombudsman program to help consumers fight with their private health insurance companies. The second is requiring that all PPO and EPO health plans assign a Primary Care Physician like HMO plans have. Any initiative to help consumers navigate health insurance and the health care system are admirable. But both initiatives lack details that would help determine if the changes are lip-stick-on-a-pig or consequential improvements.
New Covered California ombudsman
In Covered California’s 2017 health plans and rate booklet, they noted how they were working with health plans to improve consumer satisfaction.
Covered California has worked hard with health insurance companies and regulators to offer consumers access to quality care and will continue to diligently monitor all companies on a regular basis to ensure adequate networks are in place.
Of course, there has been near universal grumbling from consumers about their health insurance plans. Some of the problems encountered are narrow provider networks, faulty provider search tools, along with billing and enrollment issues. In an attempt to address some of the consumer dissatisfaction Covered California will inaugurate an ombudsman program.
Starting in 2017, Covered California will establish an ombudsman program to help consumers who experience challenges with their coverage. Covered California will help consumers navigate the process with their plan and with state agencies to resolve their individual cases. Covered California will also work with its health insurance companies and regulators to resolve any challenges consumers experience in accessing provider networks.
What can the ombudsman fix for consumers?
But what will the ombudsman actually be able to do? Certainly, the ombudsman office could investigate why a health plan has not activated and enrollment even though it was sent over by Covered California weeks earlier. They might also be able to work with a county Medi-Cal office to fix problems county eligibility workers make to Covered California accounts. Most probably, they will be answering lots of questions on the difference between deductibles, coinsurance, and copayments from consumers.
The ombudsman office won’t be able to assist consumers with many billing issues from the health plan because of HIPPA regulations. I doubt they will have any more luck with resolving why a consumer was billed for out-of-network services when the consumer selected an in-network provider from the health plans search tool. The ombudsman can’t take over the role of initiating an independent medical review when a consumer has been denied a health care service from the health plan. Those must go through either the California Department of Insurance or the Department of Managed Health Care.
PPO Primary Care Physician
Covered California will be requiring PPO and EPO plan members be assigned a Primary Care Physician (PCP).
Covered California health plans will ensure all consumers either select or are provisionally assigned a primary care physician within 60 days of effectuation into their plan, so they have an established source of care who can help them navigate the health care system. Though common for HMOs, this will be new for enrollees in PPO plans. The primary care physician role as an advocate to promote organized, coordinated care for their patients is documented to improve health outcomes. Covered California PPO members will still have the freedom to choose which doctors to see and when. Covered California will be requiring PPO and EPO plans sold through the exchange to assign a Primary Care Physician to each enrolled member.
My first thought is, “Did anyone ask if the physicians or physician assistants assigned as the PCP are capable, or even interested, in organizing a patient’s health care?” Will those physicians earn an extra dollar amount for these new tasks? Is there even software in place, universally recognized, to meet the task? Who will retain all this information and how much will it cost?
Can doctors really be a patient advocate?
PPO plans are not HMO plans, unless Covered California is trying to incrementally morph all PPO and EPO plans into HMOs. But beyond patient care, there is the big wide world of health insurance that doctors seem to have little knowledge about. For example-
- How will the PCP insure that referrals are to in-network providers? Some doctors are listed as in-network under a hospital address. But they see patients at their local office, which is out-of-network for the same health plan. Some doctors outright refuse referred patients if they don’t accept the health insurance.
- What happens if the referred doctor refuses to see the patient? Will the PCP go the extra mile and start calling other doctors to set up an appointment on behalf of the patient?
- Will they refer the patient to the least expensive provider for labs and imaging, or to a facility the doctor is associated with? Consumers with high-deductible Bronze plans need to be very cost-conscious about the price of health care services. There can be thousands of dollars of difference in cost between a procedure in a hospital and one at a local surgery center. Will the PCP do a cost analysis for the patient to help them get the best deal?
- PPO plans don’t work like HMO plans. The HMO physicians group is paid every month on behalf of a member whether the member has an office appointment or not. PPO physicians get paid only when the health plan member has an office visit. What will happen if these newly minted PCPs become overwhelmed by patient questions and don’t get paid for their assistance?
We can’t expect doctors, who are not in a highly structured HMO plan environment, to understand all the nuances of health insurance and how it might impact the patient.
Covered California is neither a consumer or patient advocate
The missing elements of California PPO and EPO health plans, to make them effective and efficient for the consumer, has been the absence of a patient and consumer advocate. Many consumers assumed that Covered California was an advocate on their behalf. In a big picture sense, they are. But on the individual level, Covered California was not set up to advocate on the part of patients in the health care system or for the consumer wrestling with a health insurance company.
I would like to think that health insurance agents pick up some of the roles of patient and consumer advocate. Some agents do go the extra-mile for their clients, but others are there just for enrollment assistance only. The PPO health plans only assist the consumer to a limited extent. They have no answer as to why the listed in-network doctor insists on seeing and billing patients at an out-of-network facility.
I really hope that both the new ombudsman and PCP assignments ease the burden for many individuals and families that are overwhelmed by the health care when they need it most – when they or a loved one becomes ill. But there are still a lot of unanswered questions about these programs. Covered California might be promising more to consumers than what these new programs can actually deliver.