For Oklahoma Senator Tom Coburn, M.D. (R-OK), the Affordable Care Act, called ACA or Obamacare, delivered a dilemma. Although the Senator might have kept his old insurance under the waiver created by President Obama for Congress, Senator Coburn courageously signed up for insurance at a health insurance exchange. After getting his new insurance, he suddenly found that his oncologist who was treating his prostate cancer was not in the provider network of his health plan.
If you were faced with this reality, what would you do? Would you have the medical office send your records to a new cancer doctor and hope she/he would continue your care and that you would like that physician? And how would you choose that doctor from those available in the new network? Or would you try to cancel your plan choice (that might not be possible) and enroll in another plan in which your former oncologist was a participating provider? Or would you negotiate with your old doctor, continue your care, but pay cash for all the services and drugs and treatments? Getting all your care for cash could get very expensive.
The decision made by Senator Coburn was a difficult one. He took the last option and decided to pay cash to continue his care with his former oncologist. And even more courageously, he made his story and decision public.
Since Senator Coburn had been a practicing obstetrician and gynecologist, he had considerable experience with health plans and choosing physicians. But his choice was probably also based on his considerable medical history of cancer and tumors. He is a survivor of melanoma in 1975, colon cancer for which he received surgery and chemotherapy in 2003, and a pituitary gland tumor which was removed and found to be benign in 2007. Now, he is battling a recurrence of his prostate cancer originally diagnosed in 2011. For Senator Coburn, I believe that making sure he is with the right physician for him must be foremost on his mind.
Of course, the senator is not the only person to be faced with the choice of keeping the doctor or switching to a new doctor in the health plan network. In my practice over the years, many patients have lost their insurance and been faced with the same problem. And each of the options above have been chosen by different people, and for each of them, that decision was a well-informed one.
Generally, my patients with limited income have switched to another cancer doctor. Some have returned for an occasional second opinion to be sure what I would recommend. Other patients stayed with their new physician who gave excellent care. A few patients, fearful of getting poorer care, have continued to see me for cash. None of those decisions was wrong, each was personal, and I only hope every patient was happy with the choice they made.
But this year, I have been seeing more of my patients suddenly faced with that decision. As more patients have been shifted into Medicaid programs, many of those plans have required them to be in an HMO and many of them were not plans in which I participate. Some employers have changed the health plan offered to the employees, and some of my patients have had to change their primary and oncology physicians. Many patients who have been faced with a decision have carefully asked the available plan administrators, before they decided on signing up for the plan, if they could still see their old physicians. And regrettably, with all the confusion in December 2013 and January 2014, some of my patients and even some of my relatives could not get any answers, and some received the wrong information.
So here are my eight tips if you (or a family member or friend) is facing a decision about new insurance and possibly having to see a different doctor:
1. If you like your current doctor, stop. Before you decide on a new health plan, call the insurance company and find out if you can keep your current doctor. Sometimes a clerk might not know. Your current medical office's manager might be able to help you.
2. You can check with a health insurance agent who can evaluate your new plan options and help you to know if your doctors are on the plan, and also if you will need new referrals to use the same doctors and specialists.
3. Some patients may have a new primary care physician (family doctor) whom they will have to ask for referrals to the same specialists they have been using. Be certain those primary care physicians will say "okay" before making the move to the new plan.
4. If you have to enroll in a new plan in which your doctor do not participate, check with your current doctors. Ask if you can get a discounted visit fee to continue to see them. If you need treatments or tests, ask what arrangements can be made (often the primary physician can request authorization for them so the tests will be covered by the insurance, but otherwise you may still have to get a participating doctor to give the treatments).
5. If you really must choose a new doctor, use the tips I give in the chapter "Finding a New Doctor" in my book Surviving American Medicine to choose the best doctor for you.
6. Remember: Even if your old doctor is listed as a provider in a health plan brochure, you might not be able to see her/him. Many plans assign patients to primary doctors in an Independent Practice Association (IPA). Each IPA is different. Your doctor may be listed as a participating provider in the health plan, but is only contracted with IPA #1. If you are assigned to IPA #2 of the health plan your doctor cannot see you because he/she is not contracted with IPA #2. This same problem can occur with HMOs and ACOs (accountable care organizations, each of which is independent and contractually different). Check first with the plan and with your primary doctor.
7. If you are getting your insurance through your employer, the Human Resources Department can usually help you navigate these choices.
8. If you are assigned to a new doctor and you do not like that care, ask for a second opinion to find the best doctor for you.
We have all heard that "An apple a day keeps the doctor away!" -- don't let the ACA, Obamacare or any health plan reform keep your favorite doctors away.