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Sutter Health, Palo Alto Medical Foundation, Blue Shield and me

Sutter Health, Palo Alto Medical Foundation, Blue Shield and me

Picture of Jondi Gumz

How do you make sense of a decision made by key players outside your coverage area that affects your community like a punch in the gut?

That is what happened when I got an email Monday afternoon containing the 4-page termination letter from Blue Shield for plan members who have doctors at Sutter Health. One of the largest doctor groups in our county, Palo Alto Medical Foundation, is affiliated with Sutter Health, which just finished a beautiful new medical office and is working on an expansion of its specialty maternity and surgery center, and I had been in touch with the PAMF spokesman before Christmas asking for an update of these negotiations with Blue Shield because Blue Shield was the sole plan offered by Covered California in our county with the PAMF doctors in network.

Of course, this would have an impact, but what exactly did it mean? It said termination, yet it mentioned a transition until June 30. Luckily, I had county market share figures for insurers (after having filed a Public Records Act).

Re-reading, I saw "higher out of pocket expense" and then began calling and emailing to people I thought could help interpret all the medical jargon.

Here's what I came up with, working on a 4 p.m. deadline and juggling a deadline story on another of my beats. 

It's an unfolding story where additional information is coming to light daily.

Photo by Robert Couse-Baker via Flickr.


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Those with PPO plans have a transition period where they can use their PPO plans at PAMF and Sutter. Sutter WILL NOT honor the contracted rates that a contract afforded them. People who use their PPO plans at Sutter or PAMF will be responsible for any expenses they charge in excess to what Blue Shield pays and Sutter charges.

Those with an HMO have a limited time to transition to a new provider. In Santa Cruz County, the physicians at Physicians Medical Group are your option.

For those of us who purchased our Blue Shield plans as individuals or families since 2010, you have an EPO. This is an Exclusive Provider Network and is NOT THE SAME AS A PPO. You have no coverage for out of network services other than an emergency. PAMF and Sutter are now an out of network provider.
Licensed/Certified Independent Agent

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I'm one of the many Blue Shield insureds who is affected by this mess. I chose Blue Shield precisely because it was the only health plan available through CoveredCalifornia that PAMF (part of Sutter) would accept. Now I'm forced either to terminate relationships with my doctors that go back 18 years or find another insurer. I've decided that the easiest thing is to abandon CoveredCalifornia and find an insurer on the individual market that PAMF will accept. I'm sorry to have to do that, because my understanding is that the long-term financial viability of CoveredCalifornia and other state-run exchanges depends upon full-pay customers like me using it to buy their insurance. I don't know whom to be angry at for failing to reach an agreement: PAMF (Sutter) or Blue Shield! (Meanwhile, an independent agent told me that he is referred all Blue Shield insureds who want to stick with PAMF to switch to a HealthnetPPOl) It's hard to imagine how regular people who don't follow health policy as closely as Jondi and I do manage to figure this out for themselves.

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Martha, a "regular" person could not figure this out. If you want to use PAMF/Sutter, you will have to leave Covered CA and go to Health Net PPO or Assurant PPO plans (they use the Aetna Signature PPO network). They are more expensive than the Blue Shield and Anthem plans because they have to pay higher costs to attract the PAMF/Sutter providers amongst others.

"Regular" people should work with local certified agents familiar with the providers in the area to help them navigate the options. They are free to use and can save you from making a large error.

Picture of Martha Shirk

Pamela,  I wrote a blog post about my experience:

I did consult a certified agent to make sure that my replacement insurance (HealthNet PPO) considered PAMF as a preferred provider.

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