After living in 25 cities, Rick Torcasso is now a resident of Santa Fe. But his primary doctor is at the Cleveland Clinic in Ohio, one of the most renowned health centers in the nation.
In order to keep his relationships with providers in Ohio, Torcasso purchased a Blue Cross Blue Shield health insurance policy through the New Mexico Health Insurance Exchange that allows him to seek care outside the state’s network of doctors.
Starting in January, however, Torcasso probably won’t have that option. Blue Cross of New Mexico has scaled back its offerings for individuals, and right now, no company in the state is offering individuals a health insurance option for 2016 that’s known as a PPO, or preferred provider organization, where patients can pick a doctor outside a contracted network.
“I go to Cleveland Clinic for my yearly exam. I know everybody there, they know me, and they’ve been taking care of me for a long time,” Torcasso said. “I’ve lived all over the country, but I have a relationship with the Cleveland Clinic going back to the 1980s.”
At age 62, he is too young for Medicare and not part of a group plan through an employer, where PPO offerings are more common. For Torcasso and others who need individual insurance, shopping is now akin to a contact sport that requires hands-on research and deep dives into the telephone and Internet.
Experts are urging consumers to take their time figuring out-of-pocket expenses and making sure their preferred doctors and hospitals are included in their health networks.
“We have friends, and they too have doctors they have known over the years and move to Santa Fe and Albuquerque and keep the same doctors. I think it’s going to be a big deal for people my age when they realize what’s going on,” Torcasso said.
The elimination of PPOs by some providers is one of two major changes for New Mexicans as they explore open enrollment options, which began last week for Medicare and starts Nov. 1 for the health care exchange, through the federal website healthcare.gov. The other development stems from a dispute between two longtime New Mexico nonprofits that will limit access to the Christus St. Vincent Regional Medical Center and its physician network for some 2,000 Presbyterian Health Plan Medicare patients.
Both trends reflect an insurance marketplace where companies compete with advertised price points, but toughen relationships with providers to control costs — while limiting patient choice. This is the new reality for thousands of frustrated consumers in New Mexico who, in the next several weeks, must give up their insurance or surrender some choices on where they seek care.
“I am going to just pick the best of the bad lot,” said Katie Stevenson, 59, who, as the former owner of the Leishman’s furniture store in Santa Fe used to shop for insurance every year for her employees. Now she has consultations at the Mayo Clinic for a chronic arthritic condition.
For most consumers who stay close to home, there are ample choices on the exchange. And premiums in New Mexico, though set to increase for a typical plan, are still among the least expensive nationally. But that won’t please everyone.
Of the 52,358 individuals who purchased a policy on the exchange for coverage this year, 35,000 went with Blue Cross Blue Shield of New Mexico, and 22,000 of those are now in a PPO, said a Blue Cross spokeswoman.
In Santa Fe County, Blue Cross has 6,235 individual members who will need to shop for new health coverage.
“The lack of a PPO option in New Mexico is one of the biggest changes this year for insurance consumers,” said Amy Dowd, director of the New Mexico Health Insurance Exchange.
Dowd encourages everyone, not just Blue Cross customers, to enter their family and financial information into the state’s health exchange portal, bewellnm.com, and see if they can get a better deal. One benefit of the exchange is the transparency in pricing, which makes comparing plans easier than ever.
“We encourage everyone to go out and shop — you might find plans with better values. Enter your information and make sure you’re receiving the maximum assistance,” Dowd said. “Don’t wait.”
In order to be covered by Jan. 1, consumers have to choose an insurance plan by Dec. 7.
When the exchange opens, consumers will find intermediate-level health plans from four providers — Presbyterian Health Plan, Molina, New Mexico Health Connections and Christus Health Plan — with an average monthly premium of about $190 after tax credits are applied.
Some 74 percent of those who purchased coverage on the exchange received an advanced tax credit in 2015, said Dowd, which reduced costs by 60 percent.
Lisa Reid, director of life and health with the Office of the Superintendent of Insurance, said insurers have done much to widen networks, and the trend is for more and more providers to accept all types of insurance. And the state is beefing up its surveillance of companies to make sure they have the specialists, hospitals and services under contract statewide to sell a product across 33 counties.
But those looking for unlimited options as far as doctors will come up empty. “Those are the people for whom it will be the biggest challenge,” Reid said.
Blue Cross Blue Shield President Kurt Shipley said most of those who receive health care in New Mexico should be able to keep their doctors and specialists with one of the other plans — Presbyterian, Molina, Christus or New Mexico Health Connections.
There has been some speculation that higher costs at Blue Cross are partly due to part-time residents buying health insurance policies in New Mexico, where premiums are below the national average, but seeking care in more expensive markets.
Shipley said all PPO customers who are residents of New Mexico have the right to go out of state for care, and there is no way to know how that affects the broader costs. Generally, however, PPO plans are 10 percent to 2o percent more expensive than other types of coverage.
“They would have had the ability to go outside the state for services if they chose to do that,” Shipley said. “It could be more expensive, but not always,” as the organization has affiliates in all 50 states and has a wide range of in-network contracts nationwide.
What did happen with the individual insurance market is that more people with chronic conditions chose a Blue Cross PPO. Shipley said that as uninsured patients seek coverage for the first time, they’re often drawn to Blue Cross because they’re not as familiar with the newer insurance carriers.
“The populations they got were healthier than ours,” Shipley said of other insurance companies. “It’s typical. … You’re probably going to pick Blue Cross if you have a lot of health care needs.”
Blue Cross Blue Shield of New Mexico lost $19 million, he said. In response, it submitted a rate increase that was not supported by the Office of the Superintendent of Insurance. Shipley said the nonprofit can sustain the losses, and it hopes to be back on the state’s health exchange in 2017 with individual offerings.
For the coming year, the only individual plan on the exchange from Blue Cross is an HMO that would not qualify for federal tax credits.
All this might seem daunting, but it’s important to remember that most of the changes are impacting those who purchase insurance individually. Consumers who get coverage through their employer or a retiree health plan will not see significant changes.
Shipley said group markets have a wide range of patients — both healthy and sick — and that members of groups have been getting regular care, so there are no cost surges for new enrollees.
“Groups tend to include everybody, the well and the sick. Groups don’t have that pent-up level of demand,” Reid said. “Individual PPOs tend to skew more toward the sick. We did see with Blue Cross that they had a high level of claims.”
New Mexico joins Illinois, Texas, Florida, New York and California in not having a PPO option on an exchange, according to Reid.
“More than ever, the writing is on the wall. It’s going to be harder for insurers of any size to keep offering PPOs in the exchange and individual markets,” writes blogger Bill Melville, a senior analyst on health care exchanges with Decisions Resources Group in Nashville, Tenn. “The pathway to exchange profitability is narrow, and the statewide PPO networks are not.”
New Mexico consumers say the state has essentially taken away their right to choose.
“What was supposed to increase all of our options has ended up shrinking them massively,” said former business owner Stevenson. “Frankly, I would have paid for a PPO, but they wouldn’t give people like us an option. It’s terrible and its bad for me, someone with a lifelong chronic illness.”
“I’d be fine to pay an increase just so I can continue to use the Cleveland Clinic,” Torcasso added. “I’m not looking for cheap insurance — I know it’s expensive. I know it’s going to cost more. At the end of the day, I want the choice.”
A dispute over Christus
The other big change for 2016 impacts Medicare and some 2,000 people in the Santa Fe area currently insured through Presbyterian Health Plan’s Medicare Advantage program. Those patients will no longer be able to use the Christus network for nonemergency care after Dec. 31.
If those patients have a Christus doctor they want to retain, they can choose another Medicare plan. If they want to stay with Presbyterian insurance, they will have to find a doctor and hospital in that network, which might mean going to Albuquerque or Española.
“Medicare Advantage seniors should know that if you choose a Presbyterian Medicare Advantage health plan during open enrollment, you will not have in-network access to our facilities or physicians in 2016,” outgoing Christus President and CEO Bruce Tassin wrote in The New Mexican on Oct. 11.
In order to remain with Christus, patients must switch to the hospital organization’s own Medicare plan — the Christus Health Plan — or choose coverage through Amerivantage, Blue Cross Blue Shield or Care Improvement Plus, Tassin stated.
It all seems petty for Don Dietz, 71, and other patients trying to navigate their own insurance plans and medical care. Both Christus and Presbyterian Health are nonprofits with a centuries-old mission to extend their healing to underserved areas.
Dietz, who owned a tour business in Santa Fe before retiring, said the member rating for Presbyterian Health Plan is high. He lives in a condominium complex behind the new Presbyterian Health clinic on St. Michael’s Drive and wants to continue seeing the group’s physicians. But he also wants access to Christus St. Vincent facilities, many within walking distance.
And his restricted access to the city’s only general hospital raises questions: What if he has emergency surgery at Christus — which would be covered by any insurance — but then gets admitted? Would the Presbyterian Medicare plan pay for that?
“I would love to stay with Presbyterian. The new clinic is a block away, the [Christus] hospital is two blocks away. I would love for them to get together so they can better serve the seniors in Santa Fe,” he said.
Carlos Moya, division director for consumer and elderly rights at the state Aging and Long-Term Services Department, said the agency is gearing up for questions about the dispute, as well as other inquiries about Medicare, insurance premiums, drug coverage and copays.
Moya and his staff have a call center in Santa Fe with 10 trained experts to provide unbiased information on Medicare options for the 300,000 state residents insured through the program.
“It’s changing all the time. That’s the hard time we have trying to stay on top of it,” Moya said.
With the Presbyterian change, he is encouraging those who have a physician or a specialist they prefer to ask the insurance carrier if that provider is in-network for the policy. It is also important when shopping for a carrier to ask about drug coverage. His support staff has an online tool that can help patients match prescription medications with the best Medicare plans.
“We always encourage people to take a look — there may be another provider offering the same medications at a lower price. There could be a plan out there that will save you money,” Moya said.
He added that this is the first time that open enrollment for Medicare, the government insurance program for those age 65 and older, coincides with enrollment for the Affordable Care Act, which requires everyone to be insured through an employer or a private insurance company.
“That’s added to the confusion,” said Moya, whose agency focuses only on seniors and Medicare.
And patients certainly don’t need more of that.