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Health Insurance Seekers Find Networks Missing Key Providers


Across the country, many consumers shopping for health insurance on government-run exchanges are discovering that some of the best-known doctors and hospitals in their region will not be part of their health plan. This is because as insurance companies try to make their plans more affordable, they're using more restrictive, so-called skinny networks of health care providers.

NPR's Wendy Kaufman reports.

WENDY KAUFMAN, BYLINE: Jeff Blank, a self-employed massage therapist, has been taking his daughter, Zoe, to Seattle Children's Hospital for years.

JEFF BLANK: Zoe is fun-loving, joyful, very curious and - did I say loving, 'cause she's very, very, very sweet; and she's very smart.

KAUFMAN: But Zoe - who's now in kindergarten, and thriving - has a very serious condition, and is monitored closely by specialists at the Pacific Northwest's premier pediatric medical facility. Her care at Seattle Children's has been covered under the family's health insurance.

KAUFMAN: But their plan, from a Premera subsidiary, is being discontinued. And when Blank looked for a new plan inside the state exchange, he discovered that most of them, including those run by Premera, do not include Seattle Children's.

BLANK: And I'm like, what's this? And I started looking in, and I'm like, oh, my word.

KAUFMAN: Seattle's Children's isn't the only marquee provider missing from many plans. So are the city's two biggest cancer centers and the University Medical Center.

ERIC EARLING: We were really focused as we prepared these new plans - really focused on trying to make sure that they're as affordable as possible.

KAUFMAN: Eric Earling is with Premera Blue Cross, one of the state's largest health insurers. He says Premera has eliminated doctors and hospitals - including Seattle Children's - where services cost more.

EARLING: A pediatric appendectomy at Children's costs over $23,000 whereas at other Seattle-area hospitals, it costs just over $14,000. So you're looking at about a 65 percent higher cost at Children's.

KAUFMAN: But Dr. Sandy Melzer, a senior vice president at Seattle Children's, calls that kind of analysis simplistic. Children's, he says, is highly specialized and gets the sickest kids.

DR. SANDY MELZER: It is unprecedented for a major children's hospital like Seattle Children's to be excluded from several health plans.

KAUFMAN: Children's has sued to keep those plans from operating within the state's insurance exchange. Melzer says Children's offers services kids can't get anywhere else.

MELZER: And we believe that the children in this community deserve to get good pediatric care, and the plans that were approved could not offer that.

KAUFMAN: And so, he says, the plans don't comply with the requirements of the Affordable Care Act. Premera answers by saying that if kids need unique services, they can go to Children's and will be fully covered under their insurance plan. But Premera will decide what's unique on a case-by-case basis. And that makes Zoe's dad, Jeff Blank, very uneasy.

BLANK: I feel it's up to my doctors to decide what and where she should get her health care, not the insurance companies deciding what's best for my daughter. It should be my doctor's decision, not my insurance company.

KAUFMAN: But Betsy Imholz, a health policy expert at Consumers Union, says when it comes to health care and insurance, things are changing.

BETSY IMHOLZ: We may not be able to have absolutely every choice that we want, if we also want to keep prices down. That's just the reality.

KAUFMAN: Imholz encourages people shopping for plans to read the fine print; and call insurance companies and providers directly, to find out what's in the plan and what's not.

IMHOLZ: But I wouldn't push the panic button simply on the basis of a particular name not being there. It may be a disappointment to some people. However, what we have found is that a higher price and big reputation doesn't always mean better care.

KAUFMAN: The insurance commissioner of Washington state, Mike Kreidler, understands that, but remains concerned that some people who buy insurance through the state exchange won't get everything they need. And Kreidler believes that more restrictive, skinny networks are likely to spread.

MIKE KREIDLER: Today, we see it inside the exchange. I think tomorrow, you're going to see it in the individual and small-group market, in ways we hadn't seen it before.

KAUFMAN: The drive to cut costs is real and while it started years ago, it has intensified with the Affordable Care Act.

Wendy Kaufman, NPR News, Seattle. Transcript provided by NPR, Copyright NPR.

Wendy Kaufman