Cancer centers limited under Covered California, state exchanges

The health care plan Mike Merkel carefully settled on last November seemed like a blessing.

The West Covina resident enrolled in the Blue Shield platinum plan for a family of four. Because he and his wife earn just above the federal maximum income level, they did not receive any subsidies or breaks in their insurance costs. But he was paying $1,000 less a year for him, his wife, Nina, and two children compared with a previous plan. He’d be getting what he wanted, he was told.

But when Nina, a breast cancer survivor, needed a follow-up visit with an oncologist at City of Hope where she had been a patient for several years, Merkel learned his plan didn’t cover visits to the cancer center.

“They lied to me about the fact that my wife could go to City of Hope,” Merkel said of Blue Shield. “It stinks. It’s like buying a Cadillac and being told you’re getting a Yugo.”

Merkel said when he bought the Blue Shield plan that was especially tailored for Covered California customers, he was told by both the carrier and a representative of the state exchange that City of Hope was part of the network.

“As far as I’m concerned, I’m screwed,” he said. “I can’t get (the services) I used to have.”

What Merkel experienced has become a common scenario after hundreds of thousands of people enrolled into health plans through Covered California beginning last October. While many such as Merkel were pleased to learn that they were saving money, some discovered that cancer centers were off limits.

“We did experience situations where patients who were in treatment in City of Hope were no longer covered,” by their plan, said Dr. Harlan Levine, chief executive of City of Hope Medical Foundation. “We had cases where new patients where being referred to us by doctors but could not be accepted.”

Levine said the center has participated in broad health plans for years, but accepts one Covered California plan: Anthem Blue Cross, PPO and EPO.

“The changes have led to new product designs and narrow providers,” Levine said of health plans. “We felt it with patients.”

The limited access to cancer centers is being seen nationwide as well, said Dr. Richard L. Schilsky, chief medical officer for the American Society of Clinical Oncology.

A survey conducted by The Associated Press earlier this year found that of the 19 centers that are part of the National Comprehensive Cancer Network, only four reported access through all insurers: the Kimmel Comprehensive Cancer at Johns Hopkins in Baltimore, Fox Chase Center in Philadelphia, Duke Cancer Institute in Durham, N.C., and Vanderbilt Ingram Cancer Center in Nashville.

“We’ve been hearing about this for some time now,” Schilsky said. “The good thing about the health exchange is that more people have coverage than ever before. But we’ve continued to hear from many states in the country that health exchanges are cutting the cancer centers from the offerings.”

Schilsky said the limited access to cancer centers does not imply that patients are receiving inferior care in community oncology practices.

“In the vast majority of cases, patients receive astounding care, but the comprehensive cancer centers offer a breadth and depth of experience and options that cannot be replicated in the community hospital setting,” Schilsky said.

He said while the Affordable Care Act made it illegal for health insurance companies to deny coverage to patients with pre-existing conditions, even cancer, the fact is the insurances narrowed the number of providers to keep premiums down.

He said his association and others are working to raise awareness about the issue as well as watching to see if patients are being affected by the switches.

“We will be watching this with great interest,” Schilsky said. “We’re committed to ensuring that cancer patients have all the best access to treatment to their care.”

It was unclear if well known cancer centers at UCLA, USC, or even Cedars-Sinai accepted those patients. There was little or no response to inquires.

“UCLA health’s physicians and hospitals are available under Covered California through Anthem Blue Cross EPOs and Health Net PPOs,” spokeswoman Dale Tate said in an e-mail response. “I am not aware of any specific issues relating to cancer patients.”

A brief look through the Anthem Blue Cross EPO directory showed 104 medical oncologists for all of Los Angeles County.

But while access to cancer centers through some plans may be limited, patients are still finding care, said Nicole Evans, spokeswoman for theCalifornia Association of Health Plans.

“The health plan will assure they have access,” she said. “It may not always be the same provider, but they will get care. If people are having trouble, we encourage them to call their health plan.”

CONSUMERS ADVISED TO ASK QUESTIONS

Dana Howard, a spokesman for Covered California, agreed, adding that networks may broaden in the future, but in the meantime consumers have to ask both insurers and providers about care.

“It is a fine dance and balance that is done to keep access broad enough, but prices low enough,” Howard said. “You can’t have a plan that has anybody and everybody whenever you want to, and have that pricing. We really worked very closely and very rigorously with the health plans who brought in the best pricing for our networks. While you’ll see some contract in one area, you’ll see it expand it to others. While we may not get the precise providers a person wants, for the price, they’re still going to get great care.”

Levine at the City of Hope said he doesn’t see those networks widening any time soon.

“I don’t really expect change coming in this coming year,” Levine said.

He said consumers can try to make change by demanding that they have more providers available.

“Everyone out there, young or old, is touched by cancer at some point, whether it is direct or through a loved one,” he said. “When purchasing insurance, people should select a plan that has an academic or, better yet, a National Cancer Institute designated cancer center. This is not only good for their family, but sends a clear message that this is what health plans need to be offering in their products.”

Meanwhile, Merkel said his wife, Nina, found an oncologist within their network, but there were only four in the San Gabriel Valley.

“I’ll admit the cost is a lot lower for us,” Merkel said. “But on the other side of it, I’m having to go find an oncologist on my own and look for prices for things like an MRI.”

This story was originally published by the Los Angeles Daily News.