Health Insurance Matters: Medical Groups

Health Insurance Matters / Harry P. Thal

Anyone who has ever sought my advice on selecting a plan to go along with their Medicare will quickly learn that I am not a great fan of the Medicare Advantage HMO plans. I am one of the top leading producers in enrollments, but that is because there are so many people of limited means living in the Kern River Valley. These plans do afford quality health care with little or no monthly premium. My objection to the plans is that you must select a Primary Care Provider (PCP) and this physician becomes the “quarterback” directing your health care.

In Kern County there are many medical groups. Some are specialty groups, such as the Hispanic Medical Group or a Psychiatric Group. I shall limit this discussion to the four groups that provide care to the Kern River Valley.

For the past half dozen years or so, we have had three medical groups that our local PCP doctors have been members of. There is the Bakersfield Family Medical Center/Heritage Group (BFMC), the Independence Medical Group (IMG) and in the last two years, QualCare IPA (QualCare). A forth group, GemCare (GEM) has been missing.

While a very viable group in the employer sponsored group marketplace, GemCare has not had a Medicare product since it sold its HMO to Blue Shield of California. Blue Shield then decided to reduce its territory and eliminated most of Kern County, just keeping select zip codes in the Bakersfield area. 2019 will be a change, as Blue Shield will once again become available to residents of the Valley.

In addition to Blue Shield, another Medicare HMO will be entering the Kern County market providing us with additional choice and benefit options. This will be announced at my “Medicare and a Movie” program on October 3 at the Reel Cinema.

So, what is a “Medical Group”? Just imagine the enormity of the task if each insurance company negotiated a separate contract with every primary care doctor, laboratory, radiologist, pharmacy as well as all the specialist doctors. It would be chaotic as well as impossible. So, doctors get together and form groups on their own, employ executives and support staff and organize themselves. The group then seeks additional doctors and other providers and markets themselves to the various insurance companies.

Some of the primary care doctors become exclusive to one particular group, such as Sienna Wellness (Jim Gutzman and Drs. Finstad and Gross) are exclusively contracted to BFMC while the Kern Valley HealthCare District (Dr. Montes and staff) are providers to all four medical groups. The other two clinics, operated by Clinica Sierra Vista are the Kern River Health Center in Wofford Heights (Dr. Abrahamson) and the Kern Valley Medical Center in Lake Isabella (Carol Kendall and Tina Heinemann) are contracted with three groups; IMG, QualCare and GemCare.
The significant importance to this is that most specialists in Bakersfield are typically contracted with only one or perhaps two of these groups. Therefore, even though your PCP might be contracted with several groups, it is under which group you enroll, thereby having access to the participating specialist.

Example would be that you want Heart Hospital and Central Cardiology as your provider for your heart problems. You must select a Primary Care Physician that is contracted with QualCareIPA. Once done, then your PCP can make the appropriate referral.

The medical groups offer much more than just access to doctors and pay the bills. They provide additional services. QualCare, for example, offers free wellness checkups at their Bakersfield facility. The check-up begins with free transportation from your home and back again, the exam, and a $25 Walmart gift card to reimburse you for your time. They have a strong desire to keep you healthy! Call my office for more information on this free service.

MARK YOUR CALENDARS for “Medicare and a Movie.” The informative educational (no selling) seminar will again be held at Reel Cinema, Wofford Heights, on October 3. There will be new HMO plans introduced for Kern County as well as a Medicare Advantage PPO plan.
Refreshments will be served. Doors open at 12:15 with the “pre-show.” Seminar is at 1:00 p.m. followed by the week’s feature film.

Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 24 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail harrythal@aol.com or visit him on the web at www.harrythal.com.


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