Losing My Physician: Are Narrow Networks the New Normal?

Thursday, May 01, 2014

Andrea Waccholtz watches her students practice. A stomach bug has lingered for months, while she tries to find a doctor who will take her new health insurance coverage. (Fred Mogul/WNYC)

Staten Island dance studio owner Andrea Wachholtz has had an off-again-on-again bug since December. At one point her stomach pain was so severe, she thought she had an ulcer, and she cancelled all classes and closed for the day.

"I have no idea what it is, but it’s not good," Wachholtz said. "I need to get that checked out."

But finding a physician using her new insurance from New York State of Health isn't as easy as she thought it would be.

Her last plan had several pages worth of physicians in the directory for her area. "But this time when they emailed it to me, I thought I was scrolling through it the wrong way, because I went through everyone in Richmond County so quickly," she said. "There are so many doctors here in this neighborhood, yet they’re not part of the network."

Instead, they're all on the other side of the island, which can take a long time to drive to when there's traffic. So Wachholtz has decided to skip using insurance at all. Instead, she will pay out of pocket to see a nearby physician she trusts.  

Wachholtz and many of the 8 million people across the country with insurance on the exchange can thank the increasing use of "narrow networks" for this dilemma. That is, fewer doctors and hospitals are considered to be in-network for each health care plan. Despite being politically unpopular, New York has encouraged health plans on the exchange to limit their networks like this in order to keep prices down. It's one of the main reasons individual insurance premiums in New York have dropped by around 40 percent since the introduction of the health exchange.

State regulators say all of the provider networks for insurance carriers in the health exchange are "adequate," meaning consumers have access to enough medical services in their area. And officials say only 200 out of 10,000 complaints have focused on the availability of doctors — most are about billing, insurance cards and other administrative details, officials said.

Insurers can offer out-of-network benefits if they want, but only a small number have done so, and none are in the metropolitan area. A proposal in the state legislature would require insurers to offer this benefit, but the fate of the bill is uncertain.

James Knickman, president of the New York State Health Foundation, said patients are being caught in between the insurance companies and doctors. He said it will take some time for the health plans to figure out how wide their networks should be.

"Make them too skinny, and they'll lose customers who'll go somewhere else," he said. "But make them too wide and insurance plans won't be able to control their costs."


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Comments [9]

DrDave from Washington State

So Andrea pays to go out of network and her insurance company pockets her premium. This is what the narrow networks were designed to do for the insurance companies. This in addition to weeding out (cherry-picking)the expensive clients with chronic diseases who won't and shouldn't give up their long time established physicians. That way they can have a portfolio of hardly ever sick people, collect their premiums, and get them to jump ship and pay out of pocket.

May. 24 2014 07:44 PM
Betty from Manhattan

How are the insurance companies deciding on what Dr.'s to include on their plans? If providers have been on the plan, but with ACA are now not on the plan, what is the criteria for a Dr. to be included or excluded? No one seems to know. I wonder if the insurance plans are wanting to keep costs down by only including Dr.'s who have provided fewer services and thus are cheaper for the insurance companies?

May. 11 2014 10:27 AM
mary from Manhattan

My family can only get insurance through the ACA exchanges because we are self employed and our current,expensive polocy is being cancelled. There are no policies offered in exchanges in NYC that allow for any out of network reimbursement. This is a problem for the person who would like to continue seeing the psychiatrist they have seen for last four years. There are very few psychiatrists in the networks and it is frightening to consider starting again w an unknown doctor. This is a huge problem that is not getting any coverage in the news about the exchanges.

May. 01 2014 11:12 PM
CK from Westchester

This must be what Pelosi meant when she said "we have to pass the bill to see what's in it." So now we see. Fixed things for the folks without insurance (limited network better than nothing)but messed up an awful lot for the existing insured population who foot a lot of the bill of their own care in out of pocket etc. So much for Obama's "if you like your doctor, you can keep your doctor." I'm not saying there are not desirable parts of ACA, I'm saying the govt. can't do things like this right. (Dems and Repubs both).

May. 01 2014 01:22 PM
Mark Horowitz, MD from New York, NY

As a primary care physician practicing in NYC, I have been a vocal supporter of the Affordable Care Act. Can we call ourselves a civilized country and have 40 million uninsured citizens? Before the phase-in of the Affordable Care Act, insurers assured participating physicians that if they were on their panels before the phase-in, they would be on their panel for exchange-based plans. Now, we are learning the truth: insurers are controlling their costs by controlling the size of their networks. I have gotten a number of phone calls from patients who have purchased exchange-based plans and are not finding my name on their panel. In some cases these are patients whom I've known for more than twenty years. Didn't Pres. Obama declare that his vision of the ACA would enable patients to continue with their own doctors? My calls to insurers, including Oscar (administered by Magnacare), Emblem and Blue Cross/Blue Shield have yielded tremendous resistance to opening up their panels and little honest information about why their panels are so restricted. Physicians, patients and regulators need to change this situation quickly.

May. 01 2014 10:42 AM
sharilyn neidhardt from Brooklyn NY

"James Knickman, president of the New York State Health Foundation, said patients are being caught in between the insurance companies and doctors. He said it will take some time for the health plans to figure out how wide their networks should be."

Patients ARE being caught out in this change, and it's us who can least afford to be. Patients in need of care are already in a vulnerable state, and expecting them to bear the discomfort of a changing system is patently unjust. Why is so much legislative care being taken to protect the insurance companies?

May. 01 2014 09:27 AM
Michael from New York

Nice story about one person's choosing to pay out of pocket rather than drive 15 minutes to a pool of perfectly capable physicians, some of whom are very likely top notch and associated with top notch hospitals.

How typical is this and how representative of the overall population is this person's choice, that it merits being the featured story in this report?

WHy was there no actual reporting and no context, explaining just how far she would have to drive and the caliber of the physicians she was choosing to not visit?

May. 01 2014 08:56 AM

For some of us in NY, there are no doctors or hospitals closer than 30 miles and most are 40 - 50 miles away. Frustrating, but that's the lot of rural living. We need many many more primary care doctors and health care professionals in the entire US. Perhaps we should allow healthcare providers from other countries set up practice in the US and compete with American providers.

May. 01 2014 08:42 AM
sharilyn neidhardt from Brooklyn NY

I'm super angry about this, because I had insurance that I liked, but my insurance was cancelled by the company to make room for the ACA plans and now I'm on an exchange plan. And now not only does my doctor not take the insurance, but the hospital he's associated with also doesn't take the insurance. Since I need surgery, I'm forced now to try to find a doctor-hospital combination who will take my terrible insurance. And there aren't really very many options! The therapy I am in for addiction recovery is also no longer covered. If I'm forced to pay out of pocket for most of my care, I fail to see how I'm better off with insurance.

May. 01 2014 07:56 AM

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