Thursday, February 19, 2015

SUTTER'S EXCLUSIVE HEALTH PLAN EXCLUDES LOCAL PHYSICIANS

SUTTER'S EXCLUSIVE HEALTH PLAN EXCLUDES LOCAL PHYSICIANS

by Kevin Caldwell, M.D. and Donna Sund, D.O.

Many readers are aware of the new local EPO Health Plan being offered by Sutter Health, Anthem, and CalPERS.  You may or may not be aware that Redwood Medical Offices and several other local offices are not currently listed on the provider panel.  Here's why:

The new EPO plan is an "Exclusive Provider Organization."  This means that in order for you to be treated, you have to go to an approved provider and an approved hospital.  None of the local independent (non-Sutter affiliated) providers we contacted were offered an opportunity to join the provider panel before the initial plan roll-out on January 8.  We learned of the plan in the middle of January, when patients approached our office with letters from Sutter Health/Anthem Blue Cross/CalPERS, offering them a new health plan in our area.  We knew nothing of the plan until patients brought us these subscriber letters, and our patients obviously had many questions and concerns.

In the past, when a new health plan was made available, especially to large local employers, the plan administrator would contact us before the roll-out to offer us an opportunity to be on the provider panel.  However, this time the list of participating doctors included only Sutter-affiliated providers (two of whom have already left the area). The only hospital on the approved list is Sutter Coast Hospital. For 30 years, Redwood Medical has always been offered participation in local health plans, and we have been providers for CalPERS/ Anthem since its onset.  In fact, we provide a significant amount of the local primary care to these many employees and their families, and have done so for decades.

When we realized our office was not on the EPO provider list, we immediately contacted Anthem to learn why not. This was the reply from Anthem Senior Managing Consultant Mark Johnson:  "Sutter is taking the lead on adding additional Del Norte County physicians into their EPO plan network providers."  Mr. Johnson added that he would forward our concern and request to be listed on the provider panel to Sutter, but we never heard back from Sutter or Anthem until later that month.

On January 27, Sutter Coast Hospital CEO Mitch Hanna told the hospital Medical Staff that he understood providers who are on Anthem's PPO list of providers were eligible to be on the EPO provider list.  He invited Medical Staff members to call him if they were interested in joining the plan. So we contacted Mr. Hanna's office the following day, indicating our interest in joining the provider list and asking for more details.  But our inquiry to Mr. Hanna about the plan's terms and restrictions has gone unanswered.  Now, halfway through the patient sign-up period, we are still not on the panel, and have not received any further information from Sutter or Anthem about the plan.

Some of our unanswered concerns about the EPO include:

(1) According to the letter sent to plan subscribers, the plan offers "no charge for inpatient or outpatient" hospitalization (as long as you go to Sutter Coast Hospital).  But according to the actual EPO Disclosure Form, there is a $250 co-pay charge for endoscopy, cataract surgery, and spinal injection, and $50 co-pay for an emergency room visit.   

 (2) According to letters from Sutter Health/CalPERS/Anthem sent out on Jan. 8 and Jan. 19, "members do not need to select a primary care physician."  Those same letters also state that the "EPO Plan is specifically designed to not require a primary care physician." But according to an email sent to a local doctor by Nora Nunn Powers, Anthem Regional Director of Provider Contracting, "the structure of the product requires that any request for referrals outside of the established/approved EPO panel need to be directed back to the primary care physician for referrals to other specialists."

 (3)  If patients present emergently to Sutter Coast Hospital and require transfer, either due to specialized needs, such as a heart attack, or because our local hospital is "full"and unable to admit more patients, can these patients be transferred, as has been traditionally done, to the closest available facility (most often Rogue Valley Medical Center), or will they be transferred to a Sutter facility at a much further distance in order to stay within the Sutter network of providers?  In addition, many patients are referred from our office to specialists in southern Oregon or Humboldt County.  Will the new EPO make it impossible for patients to see these usual specialists?


As of today, Redwood Medical Offices is still not on the EPO provider list.  We have made several attempts to learn the details of the EPO plan, but we continue to wait for answers from both Sutter and Anthem.  We hope these answers will be forthcoming, and that we will be able to continue to provide our many long-time patients with the excellent health care they deserve.


Sincerely,

Kevin Caldwell, M.D.                                                        Donna Sund, D.O.
                                      Redwood Medical Offices
                                           1240 Marshall St.
                                      Crescent City, CA  95531

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