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Where Oh Where Did My Texas PPO Go!

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Types of Health Insurance PlansThe recent decision by Blue Cross Blue Shield Texas and now Humana to discontinue their PPO plans has spelled disaster for many families seeking to find a doctor who accepts the now-offered EPO and HMO plans from those carriers.  The new plans, while ACA-compliant, are not widely accepted by doctors, and often a consumer will end up stuck with the entire bill for non-emergency care.  Furthermore, it is relatively common for the closest in-network doctor for specialist services to be more than 100 miles away – an additional burden in travel and time.

The San Antonio Express reported an example of the lack of coverage in the plight of Ken Davis, a self-employed entrepreneur from La Vernia.  His gastroenterologist and orthopedist were not covered under the new HMO plan, and neither was his wife’s specialist, who she was seeing for ongoing treatment for rheumatoid arthritis.  To further complicate matters, none of the in-network gastroenterologists would accept his HMO plan, and there wasn’t a rheumatologist within 100 miles who was considered in-network and would accept the HMO plan.

PPOs, or preferred provider organization plans, were the most popular type of plan in Texas.  Blue Cross Blue Shield stopped offering the plan on the exchange beginning the first of the year, with Humana following suit discontinuing their PPO on-exchange as well.  The shift has made finding a covered doctor, let alone a specialist, a burden to many in Texas.

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The change from the insurance carriers was one out of necessity to control costs.  As explained by Dana Forgione, chair of the University of Texas at San Antonio’s business of health program, “A PPO format is just not a luxury that the plans can afford anymore.  In order to avoid the consumer and regulatory backlash over huge premium increases, the only other option is to cut costs. And the way to cut costs is to go to a narrow, highly controlled network, where you have gatekeepers who limit access to specialists. You have selected providers who you can deliver market share to in exchange for steep discounts on pricing.  That results in unhappy patients who say, ‘I can’t get my doctor anymore, I can’t get my hospital anymore.’ And that’s frankly a fact of life. That’s the way it’s going to be.”

He also has made the prediction that carriers discontinuing PPOs will spread to other major metro areas.  At this time, PPOs are still available in the following major cities: Chicago in Illinois, St. Louis in Missouri, New Orleans in Louisiana, Detroit in Michigan, Memphis and Nashville in TN, and Portland, Oregon.  He also noted that a further factor will be the gradual aging of population increasing the number of Medicare recipients, resulting in further pressure to control costs.

The end result is more burden on consumers, both in travel time and in stress adapting to the new plans, and unfortunately the trend looks to be only starting.

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