CAlif. BLUE SHIELD NETWORK ELIMINATES 3 HOSPITALS

[NRSKarenRN, BSN, RN]

Published Friday, July 20, 2001, in the San Jose Mercury News

Patients, doctors angered over move

BLUE SHIELD NETWORK ELIMINATES 3 HOSPITALS

BY MICHAEL J. COREN

Mercury News

The move by Blue Shield of California to drop three big San Jose hospitals from its network in a contract dispute had doctors and patients fuming Thursday.

Patients, caught in a squeeze between medical providers who want more reimbursement for health care and insurers who want to keep their costs down, are finding their options for treatment narrowing dramatically.

``It's a disaster, it's horrible,'' said Renee Ross of San Jose. In the past six months, three of her doctors -- her dentist, gynecologist and orthopedist -- stopped accepting Blue Shield patients.

Ross said her experience and that of many of her friends has made her determined to find a better insurance provider.

Dan Hunsaker of Morgan Hill researched insurance companies for months before deciding on a Blue Shield health plan to cover his surgery for sleep apnea. Then, after consulting with his doctor and scheduling the surgery, his plans fell apart with the expiration of the HMO's contract with the hospital.

``That's where the frustration comes in,'' Hunsaker said. His physician still takes Blue Shield patients, Hunsaker said, ``but the hospital doesn't.''

Doctors are also unhappy with the insurers, saying they compromise patient care by eliminating hospitals from the insurers' networks.

``It puts us in an unfamiliar environment rather than using whatever facility is best for the patient,'' said Dr. Steven Schwartz, a cardiac surgeon in San Jose.

Schwartz said the most recent dispute is only the latest in an effort by insurance companies to pay less to doctors and hospitals for patient care.

``This kind of thing is the tip of the iceberg and a symptom of the whole thing falling apart at the seams,'' said Schwartz. ``As an employer, all I've seen is my insurance premiums go up. As a health provider, I haven't seen my reimbursements go up in more than a decade.''

Blue Shield representatives say patient care has not suffered despite the reduction in the number of facilities that its members may use.

``People are going to receive the care they need,'' said Blue Shield spokeswoman Michelle Naiditch. ``This is our absolute No. 1 concern and priority.''

As many as 75,000 subscribers in Santa Clara County are affected by the stalled negotiations between Blue Shield and San Jose Medical Center, Regional Medical Center of San Jose and Good Samaritan Hospital to replace a contract that expired July 1.

Many patients have resisted switching doctors, said Leslie Kelsay, spokeswoman for the three hospitals, which together treat about 5,000 Blue Shield patients each year. ``Almost 100 percent of patients are still choosing our hospitals because of their relationship with physicians and the facility,'' she said.

But Blue Shield subscribers who stay with their same physicians at the three San Jose hospitals will pay more for their medical care.

Those in a Blue Shield Preferred Provider Plan, which covers as much as 90 percent of the costs in a contract hospital, would now be generally reimbursed for about 70 percent of the costs, which already are higher in non-contract hospitals.

Those who are in a Blue Shield HMO must pay the full cost of medical care if they go to a non-Blue Shield doctor or hospital.

Although wrangling over money between doctors and medical insurers is common, some health providers say Blue Shield's reimbursements don't begin to cover the cost.

``We have negotiated better rates with everyone else,'' said Shahe Komshian, CEO of San Jose Medical Group, the doctors' organization.

Blue Shield subscribers may still use O'Connor Hospital in San Jose, Los Gatos Community Hospital and Gilroy-based St. Louise Regional Medical Center.

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Contact Michael J. Coren at [email protected].