No Blue Shield customers at Los Robles

INSURANCE WOES—Residents on Blue Shield’s PPO network must go to a hospital outside of Thousand Oaks or pay higher costs, because Los Robles Hospital lacks a contract with individual Blue Shield plans. Acornfile photo

INSURANCE WOES—Residents on Blue Shield’s PPO network must go to a hospital outside of Thousand Oaks or pay higher costs, because Los Robles Hospital lacks a contract with individual Blue Shield plans. Acorn file photo

Since it opened in 1968, Los Robles Hospital and Medical Center has been the lone major hospital in the Conejo Valley. But now, local residents who purchase their health insurance through the individual market must travel miles out of town for non-emergency hospital procedures.

That’s because the 404-bed facility on Janss Road is the only hospital in Ventura County without a contract to be in-network for Covered California or off-exchange individual Blue Shield plans.

Anthem pulled out of the individual market in Southern California on Jan. 1, leaving Blue Shield as the only Conejo Valley option other than Kaiser Permanente for those who don’t get health insurance through their place of employment or a group.

That means a Thousand Oaks resident with an individual Blue Shield PPO plan who needs a scheduled medical procedure has two choices, neither of which is easy: Make the trek to the nearest participating hospital in Simi Valley, Woodland Hills or the Oxnard Plain, or pay huge out-of-network fees.

George Geldin is a Westlake Village-based insurance agent. He said patients can still receive emergency-room care in-network regardless of their health insurance carrier (Los Robles is the only Level II trauma center in east Ventura County), but options for scheduled medical procedures are few and far between.

“It’s a very big problem,” Geldin said. “If you live in Ventura County and you’re on the individual health insurance market, options are limited.”

Individual health insurance customers in Ventura County have two choices: A Blue Shield PPO plan or Kaiser Permanente. Kaiser offers integrated managed care, which means Kaiser patients must go to a Kaiser doctor or a Kaiser hospital for care.

According to the most recent numbers released by Covered California, the state’s individual insurance marketplace, more than 16,000 people in Ventura County are covered by Blue Shield PPO plans compared to 8,000 covered by Kaiser Permanente through Covered California.

Jamshid Damooei, economics department chair at Cal Lutheran University, said Kaiser’s integrated care model, which keeps prices low by providing everything from doctor visits to hospitalizations in-house, is more cost-effective than PPO plans, which let you select your own provider. Damooei said models like Kaiser’s are becoming more popular, and PPO plans are becoming more expensive.

“As an economist, do I see a huge loss here? No,” he said. “More people are opting for managed care. Efficiency and cost-effectiveness is driving the trend.”

Kaiser can provide healthcare for a lower dollar amount, Damooei said, but it comes at the cost of choice. Kaiser patients are required to use Kaiser doctors. PPOs are a more attractive option— but also a more expensive one—for people who want to be able to choose their doctor or specialist, like a cardiologist or oncologist.

“They pay dearly for it,” he said.

When health insurance companies strike deals with hospitals, it all comes down to money, Geldin said. Insurance companies have fee-reimbursement schedules to spell out what they’re willing to pay hospitals for services. The deeply discounted rates could knock a $40,000 hospital bill down to $7,000, he said.

“Actuaries figure this out,” Geldin said. “They decide whether it’s worth it for the hospital to do business with a certain provider.”

So far, Los Robles has decided a deal with Blue Shield isn’t worth it.

Los Robles is owned by Hospital Corporation of America, a publicly traded for-profit company operating more than 170 hospitals across the United States and the United Kingdom. It reported $2.89 billion in profits in 2016.

Los Robles officials did not respond to multiple requests for comment on this story.

Jonna Constantine handles media relations for Blue Shield of California. She said Los Robles has not been part of Blue Shield’s PPO network since it was established for Covered California plans in 2014.

“Healthcare is local, and costs are an important consideration in contracting with providers,” Constantine said. “We are open to having discussions with Los Robles . . . as we are with healthcare providers throughout the state who share our goal to help ensure Californians have access to high-quality care at an affordable price.”

Damooei said nothing is set in stone because Los Robles and Blue Shield could still negotiate a compromise at any time.

“A deal is always possible,” he said.