HMO hell

Lately, Tatiana Fassieux’s phone has been ringing off the hook.

She gets call after call—dozens of them a day, sometimes—from worried senior citizens who are afraid they’re losing their medical insurance. It’s a scary thought for anyone, Fassieux acknowledged, but even more frightening for senior citizens, who are often severely limited in their health care choices by both finances and serious pre-existing health conditions that disqualify them from many care plans.

For thousands of senior citizens living in Paradise and Magalia, these aren’t empty fears. After the first of the year, almost 15,000 Butte County residents—many of them senior citizens in Paradise and Magalia—will be losing their primary-care physicians due to a major patient reshuffling by Chico-based Sierra Valley Medical Group.

Since word of the move leaked out this summer, Fassieux, who manages Health Insurance Counseling and Advocacy (HICAP), has been running damage control. She’s hosted several standing-room-only meetings to assuage the fears of those who will be affected by the changes, but in the end they are so complicated that very few seem to understand them.

That was clear at a meeting held last week at Feather River Hospital. The meeting was packed with people—almost all of them senior citizens, many of them walking only with help—who clasped lists of new doctors, phone numbers of medical groups, HMOs and descriptions of health care plans.

It was all very confusing. One man, sitting in the back, muttered under his breath, “Why even bother?” He later explained that he has prostate cancer and was given six months to live—eight years ago. Now, he said, he needs health care more than ever but is afraid that he won’t be able to get it reliably. The man, who is 80 years old, declined to give his name.

For upward of two hours at the meeting, Fassieux carefully explained the changes and answered questions from the worried audience members. Most were confused and seemed to think that they are losing their Secure Horizons Medicare supplement insurance altogether. While that isn’t happening—everyone already enrolled in the program will stay in the program, if they choose—there will be major changes with their plans.

What’s happening, she said, is this: PacifiCare, Secure Horizon’s parent company, decided to stop covering almost all non-emergency medical care provided by about 40 physicians in Paradise and Magalia, as of Jan. 1, 2002. That means that Secure Horizons patients with Ridge-based doctors have to either accept a different primary-care physician (and some have been seeing their doctors in Paradise for years); or opt out of the program entirely, keeping their current doctors and hoping they can find another insurer who is willing to insure high-cost, high-risk patients.

It also means that if they choose to stay with Secure Horizons, they will have to travel to Chico, where their new assigned doctors will be, for all medical care—including scheduled surgeries, lab work, preventative care, physical therapy, cancer treatment and dialysis. In short, they won’t be able to access doctors close to home anymore.

And that, Fassieux said, is going to be very hard on many of these patients.

“For many of these people, traveling is not an option,” she said. “And they see doctors more than many of us. Some are sick and can’t go anywhere, and some don’t even drive. It’s going to be very difficult.”

Maybe so, said Sierra Valley Medical Group CEO Dr. Alan Brookers, but his company was backed into a corner when making the decision to “depanel” the Ridge physicians this summer.

His medical group serves as a middleman between the HMO—in this case, PacifiCare—and the doctors who provide care to the HMO’s patients. Last summer, PacifiCare came to him with an ultimatum, he said—either you pull out of Paradise or we’re pulling out of Butte County entirely. The health care giant, based in Orange County, is Sierra Valley’s biggest client, Brookers said.

“When we looked at this decision, we thought, ‘This is really an ugly baby,'” he said. “'No one is going to be happy either way—either the people up in Paradise lose their doctors or everyone in Butte County loses Secure Horizons and PacifiCare. … It wasn’t an easy decision, but it was the best one we could have made.”

PacifiCare, he said, had been losing money on its Paradise-Magalia Secure Horizons patients for the past year and could no longer afford to “leak like a sieve.” The company had to tighten its belt and chose to do it in Butte County—especially on the Ridge, where the rising cost of caring for the high number of senior citizens there was driving the company toward the red.

“It was strictly a business decision,” Brookers said.

While Secure Horizons patients are the largest single block of patients who will be affected by the shift, they are not the only ones that will be. Those covered under several employer-sponsored HMOs—about 10,000 people—will also no longer be covered at Paradise-Magalia physicians.

But the difference between that and the Secure Horizons patients’ predicaments, Fassieux said, is that those on employer-sponsored coverage plans have vastly more options than do the Secure Horizons patients.

“They can opt to switch to a PPO and stay with their current doctor [which generally costs the employee significantly more], or just take another doctor and keep their plan,” Fassieux said. “Getting around to a new doctor isn’t such a big deal for them.”

As could be expected, the move wasn’t popular among the Ridge doctors who will lose thousands of their patients next year. One Paradise doctor, who didn’t want his name used in print, said his practice (which he shares with another doctor) will lose upward of $1 million a year because of the switch.

“It’s going to be hard,” he said. “There’s just no two ways about it. … And the sad thing is, we get people in here every day who are just shocked about it and don’t know what to do. They don’t know Chico doctors, and they’re used to coming here.”

Wayne Firch, the president of Feather River Hospital, said he’s not sure exactly how the reshuffle will affect the hospital. Most of the physicians in Paradise are affiliated with Feather River Hospital, however, so it is certain to affect the hospital dramatically.

“We’re hearing a lot of confusion from people,” he said. “But don’t know how things are going to shake out.”

He said that Feather River is waiting until after the first of the year, when the changes take effect, to see exactly how many patients the hospital’s doctors will lose. He expects a large number of affected patients to opt into plans that allow them to stay with Ridge doctors but didn’t know how many would follow through and be accepted.

“We’re pretty distressed about the whole thing," Firch said. "I know there’s business reasons behind it, but we’re still here to take care of patients. We’re not going anywhere."