empty hospital bed

Summary: When insurance companies and providers can’t come to agreement on payments, networks become narrower. The results? People have to make different choices — either keep their insurance policy, or keep their doctors, or some other choice. Here’s one California woman’s story of how her saga is playing out — with the twist that she’s Martha Shirk, program consultant to the California Endowment Health Journalism Fellowship and a senior fellow there, after 23 years as a reporter at The St. Louis Post-Dispatch. Also, both the insurer and the provider are nonprofits, and both accuse the other of being, well, moneygrubbers. Click to read more, or ….




“The concept of narrow networks became personal to me this week when my insurer, Blue Shield, informed me that it would no longer consider my health care provider, the Palo Alto Medical Foundation, a preferred provider after June 30, which meant that if I wished to continue to see my doctors there, I would have to pay about 50 percent of the billed costs, compared with the 20 percent I now pay under my gold-level individual policy, purchased through Covered California at a cost of $1,065 a month,” Shirk writes.

“Similar letters went out to hundreds of thousands of other northern and central Californians who use healthcare providers affiliated with Sutter Health Care, as PAMF is — 140,573 HMO members and 139,338 PPO members. Both individual and group policyholders are affected.

“In the letters, Blue Shield provided no explanation for its failure to reach agreement with Sutter Health, though in subsequent press accounts it has argued that Sutter’s charges are much higher than other Northern California providers. Sutter has publicly accused Blue Shield of trying to lower its costs. ‘This is really about a very large and powerful health-insurance company trying to cut back on the money it spends on actual patient care,’ Bill Gleeson, a spokesman for Sutter Health, told the Palo Alto Weekly. On its website, PAMF wrote, ‘We would very much like to be part of the Blue Shield provider network, and we made the insurance company an extremely fair and reasonable offer.’

“I don’t know who to be mad at, Blue Shield or Sutter/PAMF. (Both, incidentally, are incorporated as not-for-profits.) I am disappointed at the situation, because I thought that enactment of the Affordable Care Act meant my worries over health insurance were behind me.” Martha Shirk, “The narrowing of networks hits home,” Reporting on Health.

Related: In a comparable California story, Stanford Health terminated its contract with Anthem Blue Cross last September. Anthem fired back by saying that Stanford Health charges a lot, citing our PriceCheck data. Read the blog post here from partner Lisa Aliferis at KQED in San Francisco.



Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...