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Access to doctors a challenge under ACA

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The Affordable Care Act was expected to reduce the number of people turning to emergency rooms for care because it would result in millions of Americans securing health insurance and finding primary care physicians.

But even as the health insurance rolls have surged, emergency room visits are rising at many facilities nationwide, including in San Diego County.

The main reason for the trend is that many of the newly insured are struggling to gain access to primary care doctors, said participants at a recent executive roundtable at The Daily Transcript sponsored by Anthem Blue Cross.

They highlighted that most of those recently obtaining insurance statewide and locally have Medi-Cal, the state's Medicaid program that serves low-income people.

Many doctors are deciding not to accept patients with insurance through the program or have long waits for appointments, so those who previously lacked insurance are continuing their pattern of going to the emergency room when they need care.

“They normally should go to a private practice and get an appointment, but what they’ve found is they have no access because private practice docs don’t want to take that,” said Chris Burns, executive vice president of operations at EA Health in Solana Beach. “So they go back to the [emergency room].”

Burns, whose company provides on-call compensation programs to health-care organizations across the country, said the plans offered through the Covered California exchange aren’t much better when it comes to reimbursement rates.

He called those plans “Medi-Cal dressed up with a Blue Shield or Blue Cross logo on it.”

Another reason patients head to the emergency room is they know they must be assessed and stabilized there, said Tom Gehring, CEO of the San Diego County Medical Society Foundation.

He also said it was unrealistic to expect Medi-Cal beneficiaries to have increased access to doctors when many physicians are declining to accept such patients.

“We have doubled the number of patients and reduced the number of doctors,” Gehring said. “Are we expecting some magic to occur here?”

A recent report issued by Health Policy Alternatives found that more than half of the providers listed by Medicaid managed care plans nationwide could not offer appointments to enrollees.

Meanwhile, about three-quarters of more than 2,000 emergency room doctors surveyed this spring reported that emergency room visits have increased from early 2014, according to the American College of Emergency Physicians.

A similar poll a year ago found that less than 50 percent of ER physicians reported more visits.

Dimitrios Alexiou -- president and CEO of the Hospital Association of San Diego and Imperial Counties -- said more emergency room visits means greater costs for hospitals, including staffing. But low Medi-Cal reimbursement rates from the state prevent hospitals from recouping the costs of care.

Alexiou and other participants said that increasing reimbursement rates would alleviate the rising use of emergency rooms because more doctors would accept Medi-Cal patients.

“That gets the doctor seeing them and it gets them out of the emergency departments, so you are actually able to see the people who have the true emergencies,” Alexiou said.

Steven Scott, chief operating officer at Anthem Blue Cross, said when discussing access, it is important to distinguish between Medi-Cal enrollees and those enrolled in private insurance plans through the health insurance exchange.

Consumers enrolled in Anthem plans offered through the exchange are not having trouble finding primary care physicians that accept their insurance, said Scott.

But Gehring said one of the Medical Society Foundation’s concerns with the exchanges is that they include plans with a listed network of health care providers that are often “narrow or phantom.”

“We did some surveys that indicated a significant number of folks who were listed as being a fill-in-the-blank provider weren’t,” he said.

Scott said Anthem has made “tremendous progress” ensuring that provider directories for its plans on the exchange are more accurate than they were during the first open enrollment period under the Affordable Care Act, from Oct. 2013 to the end of March 2014.

The insurer has improved the accuracy of the directories by working with health-care providers to keep the directories updated.

“Many consumers found in the first year that some information wasn’t as current as it should have been,” Scott said. “That was really a rallying cry for the industry to take ownership and make sure the consumer experience was as advertised.”

The federal health care reform law has also created challenges for businesses, other participants said.

Lori McKinney, chief financial officer at McKinney Advisory Group in San Diego, said her full service real-estate firm could not afford to maintain grandfathered status for its previous health plan under the Affordable Care Act, so it switched to a different plan.

As part of the new plan, employees have mentioned the “sticker shock” of higher deductibles and co-pays, she said.

“They are having to pay a lot more than they used to,” said McKinney.

Rachel Jobin, benefits manager at ViaSat Inc. (Nasdaq: VSAT), said there is a lot of confusion among employees there about the impacts of the Affordable Care Act on their health insurance.

News reports also often prompt questions about whether changes will alter their insurance plan or the doctors they can see.

Jobin said her department at the Carlsbad-based broadband and communication technology company has tried to help employees, but personal research is also necessary.

“There is a lot of work you have to do individually to figure out what applies to you and how to use [the plan] well,” she said.

Jan Perez, vice president for human resources at INDUS Technology Inc., agreed.

She said many employees with insurance through the San Diego-based defense firm have not paid enough attention to the changes to their plans, which has caused them to panic when they try to complete their enrollment at the last minute.

“They don’t understand what they are supposed to do,” Perez said.

* Related content: Emerging trends in health plans: Insurers, providers working together


Roundtable participants

Dimitrios Alexiou, President/CEO, Hospital Association of San Diego and Imperial Counties

Chris Burns, Executive Vice President of Operations, EA Health

Tom Gehring, Chief Executive Officer, San Diego County Medical Society Foundation

Rachel Jobin, Benefits & Wellness Manager, ViaSat Inc.

Lori McKinney, Chief Financial Officer, McKinney Advisory Group

Jan Perez, Vice President for Human Resources, INDUS Technology Inc.

Steven Scott, Chief Operating Officer, Anthem Blue Cross (sponsor)

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