A July 2016 Health Affairs article looked at the adequacy of provider networks for plans sold through insurance Marketplaces established under the Affordable Care Act by conducting a “secret shopper” survey of 743 primary care providers from five of California’s nineteen insurance Marketplace pricing regions in the Summer of 2015. They found less than 30% of patients were able to schedule an appointment with the first physician provider they called. The majority of the provider network information was inaccurate or incorrect.
This causes consumers and patients to have difficulty accessing medical care. Healthplans clearly are either purposefully or negligently misleading consumers and potentially endangering patients. This lack of diligence is further evidence that the health plans are shirking their responsibilities to providing adequate information to patients and consumers.
The study focused on Blue Shield of California and Anthem Blue Cross plans sold to individuals and families through the state health insurance exchange and in the open market.
About 10 percent of the time, the providers either were no longer with the medical group listed in the directory or never had been.In about 30 percent of cases, the callers were told that the doctor had a different specialty than the one listed in the directory. Roughly 20 percent of the time, the callers were unable to reach the doctors at the numbers listed in the directories — despite repeated attempts — because the lines were disconnected, messages weren’t returned, or for other reasons. In about 10 percent of the cases, the doctors did not accept new patients.
In November, the state Department of Managed Health Care fined Blue Shield $350,000 and Anthem $250,000 for “unacceptable inaccuracies.
A California law Senate Bill 137 (Hernandez) took effect July 1, 2016 that requires insurers to update their online directories once a week and their printed ones every quarter.
Consumers Union conducted its own informal secret shopper survey in 2014 and 2015, in the San Francisco area, and got similar results, Imholz noted.
In addition to the problems with provider directories, the Health Affairs study also found that shoppers with “urgent” health problems such as high fevers or heavy bleeding during menstruation faced wait times of eight to 12 days to get an appointment.
“As our analysis has shown,” the study concludes, “access to health insurance is not necessarily synonymous with access to health care services.”