<p>CF: OMG…I had not drawn that connection but it’s spot on. </p>
<p>As an engineer my reaction was often…Marketing told the customer we could do/would deliver WHAAAAAT!!! It’s not possible to do that given our present system/technology/infrastructure/staffing etc… Oh, I see…delivery of what was promised is not as important as closing the sale…uh huh, okay…make it look like it does what you said it would do…okay…we’re banking on the customer not running the newly delivered product through all the features right off the bat…hopefully they will be so happy with what they see at the top level that we will have time to scramble like heck to either actually deliver what was promised…or even better yet…we can just convince them that we’ve changed things in such a way that they are getting what they didn’t know they needed or wanted. Okay, got it…is it time for lunch and can we put that on the customers bill?</p>
<p>As representatives of the government, I believe that federal (and state?) laws protect them from doing their regular duties, even if it results in providing bad information unknowingly (which is easy to do since the law is so complex). Correct, calmom?</p>
<p>Of course, they are not protected against fraud.</p>
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<p>Again, those that built Covered Cal – the program and not the website – are some of the smartest health care experts in the state. They built that small EPO plan on purpose. It’s designed for the masses of residents, not the small few who are well off enough to have a college-aged kid attending college of of the area. Looked at another way: this is no different than many in-state HMO’s that only provide emergency coverage for OOS college students. Sure, some HMO’s do provide non-emergency coverage to college students OOS, but some/many do not and never have. </p>
<p>Thus, such ‘fixes’ are not legal or financially/politically practicable.</p>
<p>Bluebayou, you may be misunderstanding the nature of the EPOs in Santa Cruz County. </p>
<p>It was Blue Shield’s choice to offer an EPO in Santa Cruz County. No Covered California regulations forced that choice. It would have been legal for Blue Shield to offer a PPO instead. A PPO would have been more expensive, and Santa Cruz is an exceptionally expensive area for health care that has a lot of low-income agricultural workers living in it, so presumably Blue Shield did everything they could to lower costs.</p>
<p>CF: you may be misunderstanding the nature of the role of the State and Covered California, which has to approve all plans offered within the State. So, BS could not offer a small EPO if the state did not concur that the lower cost was a worthwhile tradeoff to a more limited network.</p>
<p>(With all due respect, not EVERYthing is the fault of the big, bad insurers. Yes, the do stupid things, but they also don’t hire the best and the brightest. That is one reason why the state regulates them. But with regulation, comes state responsibility for the outcomes.)</p>
<p>When you say “the people that built Covered California” here are you talking about employees of Blue Shield creating the insurance plans for Santa Cruz County? If so, then we have a terminological dispute. I would not call an insurance plan sold both on the exchange and off the exchange “Covered California;” I would call it “individual insurance.” But this is a minor matter.</p>
<p>We agree, though, that Blue Shield built the small EPO on purpose, to lower costs. Whether the regulators should have approved it is another matter. I’m not convinced that dietz’s solution would be an improvement.</p>
<p>I don’t think that making a small EPO in Santa Cruz County was a stupid thing. I also wonder about dietz’s idea that health plans in Santa Cruz County should allow in-network access to providers in Santa Clara and San Mateo Counties. If I were a provider in Santa Clara County, I might demand higher rates for out-of-county patients than for local patients, just because people in Santa Cruz County who go over the mountain for care are likely to be sicker on average than people who stay in the county. Think about it; if you have the sniffles, you’ll be happy to go to the doctor down the street, but if you have something more serious you might want to cast a wider net for your providers.</p>
<p>The net result of our small EPO area is that those customers have much less access to cutting edge health care than PPO customers. The question is whether or not the customers knew the conditions of the price/access tradeoff. From my limited vantage point, the customers I know did not realize the limitations. And, until these limitations are made clear before purchase, it is not reasonable to assume that the low income (highly subsidized or Medical recipients) would choose this limited plan. If you receive subsidize to the point where the plans basically cost you the same, why would you choose the limited one instead of the one with a much larger network. That said, I do not know what the actual premium difference is between BS EPO/ Bronze and Healthnet PPO/Bronze for the subsidized.</p>
<p>I think the reason Santa Cruz is a high cost area is at least in very large part due to the fact that California’s main predatory (and most expensive) health care operator is the predominate provider in the area.</p>
<p>Dietz, I am in agreement with you about full and complete disclosure for all plans. I think insurers in general have done a poor job making clear exactly what their customers are buying. I hope to see better enforcement of existing regulations, and new regulations as necessary, to ameliorate this situation.</p>
<p>California regulators also need to take a hard look at network adequacy, in general and specifically in the EPO areas. I’m less concerned about the few people needing cutting edge health care than the many people needing non-cutting-edge health care who might be unable to access it. There are existing ways for people needing specialized care to get it: internal coverage appeals and then external coverage appeals. But if access to routine care is a problem, as you say it is, because of a lack of providers, that needs to be dealt with.</p>
<p>I’d say potentially “less access to cutting edge health care than PPO customers.” Nothing says there aren’t good, up-to-date providers/technology in SC. To me, the focus should be on those who do need a consult, lab reading or further care in SF (and/or Stanford) - which is functionally excluded, at the start. Yes, there is an appeals process- but I think it needs to be streamlined, greased- maybe even generous, under specified conditions- for an orphan county. And, this isn’t solely about families with college kids. </p>
<p>That sounds right to me. (Although Santa Cruz County residents would be more likely to want to go to San Jose or the South Bay than all the way to San Francisco.)</p>
<p>Edited to add: Some of this goes to network adequacy. if a patient needs some normal lab test, and can’t get it in their network in Santa Cruz County, then the network is inadequate. There are medical labs in Santa Cruz; it’s not THAT small. </p>
<p>OTOH, if the patient has some rare disease, for which there is no in-network care, that’s not a network issue but an issue about how patients who need coverage for out of network care get that coverage.</p>
<p>I don’t have an issue with folks getting an exception, when it’s justified. “My doctor in wants me to use his lab in SF” may not be.<br>
I want to point out that not all ultra-level care does include “choice.” Some may want to see how doc assignments are actually done, at various cancer clinics, eg. And, as laymen, I am not sure word of mouth, someone else’s particular needs, where a doc went to med school or how Healthgrades participants rate the office, is what I would go with, anyway.</p>
<p>Re: Navigators. As I recall, they do not have to be licensed insurance brokers. They only had minimal training and there were reports months ago that some of them were ex-cons. They likely knew less about Covered California than people on this thread.</p>
<p>Reports some were ex-cons? What do you want us to make of that? That there’s some extraordinary risk in using a navigator? Or that they found one or two? Yesterday, I had some fun with online sites about rhetoric, how one can drop suggestions that alarm or mislead, out of proportion to reality. False dilemmas, etc. Pretty interesting, after months on this thread. </p>
<p>Navigators is a fancy word for call center worker. They get 2 weeks of training and read from a prepared script. The reports about some being ex-cons came up when concerns were raised about giving private info to these people who did not even go through a background check. Many were hired as political favors to Obamacare support groups. Remember the one who got fired for telling Fox News most callers were not happy? I mean, this is actually quite comical. And tragic.</p>
<p>Some of them handled people live. They had tables at libraries and community centers, etc. But without proper training and licensure, I’m sure much of the information given out was wrong. </p>
<p>That’s not correct. Some of the call center workers were not navigators, and a lot of navigators worked in in-person drop-in clinics.</p>
<p>I also find the comment “some of them were ex-cons” troubling. If a person has served his debt to society, he should be able to get a job. Seems to me a healthcare navigator would be a good choice-- it doesn’t require a huge amount of training and it doesn’t offer obvious temptations to criminality.</p>
<p>The navigator concept is not original with the ACA. Medicare has had navigators for a while.</p>
<p>Temptations to criminality? They are handling personal information that could be used for identity theft. And as for training, why do insurance brokers require a license but navigators don’t. Makes no sense. </p>