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Patients With Low-Cost Insurance Struggle To Find Specialists

Wed, July 16, 2014 8:11pm

Story by Carrie Feibel




Listen to this story on npr.org »

Dr. Charu Sawhney examines patient Mang Caan. Sawhney supports the Affordable Care Act, but has been frustrated by how difficult it is to find specialists who accept some of the plans her patients bought.

The Hope Clinic in southwest Houston is in the very heart of Asia Town, a part of the city where bland strip malls hide culinary treasures — Vietnamese pho, Malaysian noodles, Sichuan rabbit and bubble tea.

Inside the clinic, internist Charu Sawhney sees patients from many countries and circumstances. She's a big believer in the Affordable Care Act since most of her patients have been uninsured. She actively pushed many of them to sign up for the new plans.

But now she's seeing something she didn't expect. When patients need treatment unavailable at the clinic, it's been hard to find specialists and hospitals that accept the insurance.

"I was so consumed with just getting people to sign up," she says, "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 her patients picked lower-cost plans, she says, "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 to Houston who purchased a Blue Cross Blue Shield HMO silver plan. Soon after, he was diagnosed with stomach cancer. Sawhney found an oncologist to coordinate his treatment, but she and the oncologist ran into trouble trying to schedule chemotherapy and radiation. "The process just isn't as easy as we thought it would be," she says.

That's because 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 the hospitals that the patient's oncologist, 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," says Zhang. Eventually Zhang found one who took the insurance, though they'd never worked together. After the surgery, Zhang tried to set up the patient's chemotherapy and radiation at Houston Methodist. But that hospital wasn't taking the plan.

Zhang says he cannot refer patients with these narrow plans to the specialists he thinks are best, and that's a problem if the cancer is particularly complicated.

"You have limited options. So you're like a second-class citizen, you know. That's my feeling, you have this insurance and you cannot see certain doctors," he says.

Sawhney was less surprised by the barriers. Medicaid patients have similar problems finding doctors, and her uninsured patients have always struggled to find care. But she thought the Affordable Care Act would be an improvement.

Her patient with stomach cancer thought so too. He asked not to be identified because he has not shared his diagnosis with close family members.

"The (insurance) agent said that a lot of doctors will accept that insurance -- but when I got sick I found out nobody wants that kind of insurance."

The biggest irony, she added, is that even Harris Health, the county-wide public hospital system in Houston, doesn't take all the new marketplace plans. Yet Sawhney can still send uninsured patients there for cancer treatment. As people learn that some doors are closed, she worries people will decide insurance isn't worth the money.

"I don't want patients to get discouraged," she says. "I don't want patients when they have a choice again to say, 'You know what? I'm just not going to sign up because it doesn't matter if I have insurance or I don't have insurance, I still have problems getting health care.' "

Narrow networks of doctors and hospitals aren't new, but they've attracted attention with the rollout of the Affordable Care Act. Analysts point out that narrow networks are a powerful tool for insurance companies seeking to control costs – especially since they can no longer control costs by excluding sick people or adjusting premiums by gender or age.

By restricting the choices in a plan, the insurer can promise more customers for the doctors and hospitals that are included. In exchange, the insurers can get a break on what they pay those doctors and hospitals.

The industry's position is that patients have choices. Plans with access to more hospitals and specialists are available, but usually at a higher price.

Louis Adams is a spokesperson for Blue Cross Blue Shield of Texas. "Our goal was to offer an array of plan choices," he says. "We created more focused networks as a way to offer a broad range of plans with lower premium prices."

Sawhney and Zhang eventually found a place for the patient to get chemotherapy and radiation.

Despite the delays and difficulties, Sawhney still believes it's better to have insurance, and she still believes in the law. But, she says, from now on she'll tell her patients to shop more carefully, taking into account price and whether they have a chronic illness. It won't be about the cheapest plan anymore, but rather the plan that best meets their medical needs.

This story is part of a reporting partnership between NPR, Houston Public Media and Kaiser Health News.

Copyright 2014 KUHF-FM. To see more, visit http://www.houstonpublicmedia.org.