Sansum Clinic — one of Santa Barbara County's major providers of primary and specialty medical care — is not signed up to be a provider for any of the Covered California exchange medical plans, even though officials there say they fully intend to be included.
“We were unaware if we were in or out until I think the last month or so,” CEO Dr. Kurt Ransohoff said Friday. “That was news to us. We had operated under the assumption we would be in the network.”
Sansum Clinic’s primary and specialty care services handle 61,000 patient visits every month, and neither type of provider is included in the exchange’s insurance plans.
That means, if nothing changes, people who buy plans through the state exchange won’t be able to use their insurance to see doctors at Sansum Clinic next year.
“Trust me, we’re every bit as frustrated as anybody with the uncertainty and the possibility of a disruption of service,” Ransohoff said.
Sansum is negotiating with Anthem Blue Cross and Blue Shield – the only two insurance companies with plans on the state exchange for Santa Barbara County – to agree on the terms of participation.
The issue is over reimbursement rates – how much the insurance companies will pay Sansum providers.
“We’re aware that there’s a need to lower health-care costs, so we have offered to take a significant discount to participate,” Ransohoff said. “Our definition of a significant discount and their definition of a significant discount are different.
"We’re a nonprofit community organization with a very narrow margin; They’re a very large multi-billion-dollar insurance company.”
He hopes to have an agreement in place by January, but says the current offerings are unacceptable.
“We would be unable to offer the services that we offer to the community at the rates that they’re suggesting,” he said.
“Our board has authorized us to try and work it out, to be willing to cut into our very thin margin to be able to serve the needs of the community. If we cut all the way through our margin and go into an unsustainable financial situation, that’s not going to help anybody.”
The exchange goes into effect in January, and group plans aren't expected to change; The coverage issue is with people who will buy on the exchange or have individual policies now.
The exchange opened for pre-enrollment this week, along with the government shutdown as a result of a budget stalemate after Republican legislators in the House of Representatives tried to defund the Patient Protection and Affordable Care Act, which Democrats in the Senate and the White House said they would not accept.
People can start browsing plans and benefits on the website.
There is a lot of uncertainty about what providers will be included in the exchange plan networks, which are expected to be “very narrow,” Ransohoff said.
“What we don’t know is, will the people with individual policies now continue to have access to the broader network, or will they only have access to this narrow network? We don’t have the answer to that.”
It’s still early, and there may be more clarity even a few weeks down the road, Ransohoff said.
“It might be good to shop and look around now, but if I were encouraging someone, I would tell them to wait to purchase until they have a better idea of what they’re purchasing.”
Sansum Clinic started in the 1920s, and has been taking care of patients through every kind of insurance change.
“Whatever kind of insurance the community wants to get, we figured out a way to provide it. That’s our intention, but this is new terrain,” he said.