CALIFORNIA, USA — Over the years, licensed therapist Sarah Soroken has heard from her patients again and again about what a miserable experience it can be to find a mental health provider who actually takes their insurance. But one patient stands out.
Soroken said she was working at Kaiser’s Vallejo Medical Center in 2022 when a college-aged woman was admitted to the hospital’s emergency room after she attempted suicide.
The patient, Soroken said, gave up and tried to take her own life after she called a list of 50 mental-health providers who were listed as taking Kaiser’s insurance plan, but none would see her, or they didn’t actually take her insurance.
“This patient now has the traumas of a suicide attempt and having been harmed by our health care system to add to their treatment needs,” Soroken told the Senate Health Committee earlier this month.
Soroken, who no longer works for Kaiser, testified in support of Assemblymember Chris Holden’s Assembly Bill 236. The legislation from the Pasadena Democrat would give state regulators authority to fine insurers if their lists of in-network doctors, hospitals, mental health workers, labs and imaging centers aren’t up-to-date and accurate.
The bill tackling what are disparagingly called “ghost networks” has so far passed the Assembly and the Senate Health Committees with only Republicans in opposition, and despite the lobbying powerhouses representing California doctors and insurers fighting the bill every step of the way. Doctors and insurers blame each other for problems in the directories, but they argue the bill is unnecessary, burdensome on them and that laws on the books already address the problem.
Combined, the groups have given at least $4.7 million to California legislators since 2015, according to the Digital Democracy database.
State health agency cites huge costs
Along with opposition from influential lobbyists for doctors and insurers, the measure also received a lukewarm response from the state agency that would enforce the bill if it becomes law.
As the Legislature and Gov. Gavin Newsom sought to address a $30 billion budget deficit this year, the Department of Managed Health Care estimated that the bill would cost $12 million to bring on “additional staff.” According to the bill’s analysis, the new employees are needed to develop regulations, forms and to monitor “provider directory accuracy.”
The estimate of $12 million is the equivalent of 80 employees each making $150,000 a year – figures that could alarm Newsom’s budget team and the lawmakers who dole out cash to state agencies on the Senate Appropriations Committee, where the bill will be considered in the coming weeks.
The department didn’t respond to CalMatters’ request to explain its estimate. In a one-paragraph emailed statement, Kevin Durawa, a department spokesperson, said the estimate may be out of date since the bill was recently amended.
“The department is reviewing the amendments to the bill and how they may impact the fiscal estimate,” Durawa said.
Ken Cooley, a former Democratic Assembly member from Sacramento County who sat on the Assembly Insurance Committee, said he wouldn’t be surprised that the department analyzed the bill “with a vengeance” to possibly overestimate the costs.
“If they don’t like it, if they think it’s the wrong priority, whatever it is, they would be remiss if they didn’t try to lay out every argument,” he said.
But Cooley said solving the problem of inaccurate provider lists is worth fighting for.
“I’m not familiar with the specific bill, but I certainly understand what it means to be a consumer of health care,” he said. “And having accurate lists is actually pretty damn vital to the wellbeing of people.”
Why ‘ghost networks’ are a problem
Holden, the bill’s author, didn’t respond to multiple interview requests. He told the Senate Health Committee that a law on the books since 2015 requires insurers to maintain accurate directories of providers in their networks, but they haven’t been doing it, leading to “rampant directory inaccuracies.”
His office told legislators that recent studies found that some smaller health plans have inaccuracy rates as high as 80%, and some major plans have inaccurate information for 20% to 38% of providers.
Holden’s bill would require an insurer’s provider directory to be at least 60% accurate by this time next year and 95% accurate by July 1, 2028. The insurers would face fines up to $10,000 for every 1,000 enrolled customers each year if they didn’t hit the benchmarks. Kaiser, for instance, says it provides care to 9.4 million Californians.
The bill also says patients who mistakenly use an out-of-network doctor due to inaccurate information from provider lists cannot be charged out-of-network rates.
Doctors and insurers oppose the bill
At the Senate Health Committee earlier this month, the insurers weren’t thrilled with the proposal. They blamed doctors for the inaccuracies in their provider lists.
“The accuracy of each individual provider directory is reliant upon practitioners and medical groups maintaining accurate records,” Jedd Hampton, a lobbyist for the California Association of Health Plans, told the committee.
The California Medical Association, representing the state’s physicians, argues that insurers – not doctors – are the ones responsible for maintaining their directories and ensuring they’re up-to-date. Doctors fear that if insurers are fined, the costs could be passed to them. They’re also concerned about losing out-of-network payments due to inaccurate lists provided by insurers.
The group’s lobbyist, Brandon Marchy, said those requirements would absolve health plans “of their requirement to maintain accurate directories … by paying not what an out-of-network rate would be.”
Soroken, the therapist who saw the suicidal Kaiser patient, said that Californians pay their insurers and health care providers well. They deserve to have accurate, up-to-date lists of those who’ll take their insurance, she said, especially when they’re at their most vulnerable.
“We would be negligent if we didn’t do everything in our power to ensure patients get the health care they need … and are legally entitled to,” she said.
Kaiser hasn’t taken position on the bill, and a spokesperson declined to address Soroken’s testimony about her suicidal patient.
The Oakland-based health care giant is already under scrutiny because of patient complaints about delays in obtaining mental health care. Last year, it agreed to pay a $200 million settlement to resolve a state investigation into its behavioral health system. In 2022, about 2,000 of its mental health workers went on strike over high caseloads and what they described as unreasonable working conditions.
“We at Kaiser Permanente are working hard to ensure that we are meeting the mental health care needs of our members and our communities,” Kaiser spokesperson Kerri Leedy said in an email. “Over the past several years, we have increased our staffing and facilities to help meet the growing need.”
This article was originally published by CalMatters.
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