LOS ANGELES — Elba Ramirez wasn’t sure her customers would go for it. After all, these are people who line up for the mucho macho burrito, bacon-wrapped hot dog and the cheesy nacho supreme plate.

Would they trade rice and beans for fruit and greens? Tasty beef for lean meats? Yes, as it turns out.

As soon as photos and descriptions of the new, healthier plates went up on the side of her lunch truck, people started ordering. The turkey burger was an instant hit, as was the grilled chicken breast salad. Sales climbed.

“The people are looking for food that is fresh and healthy,” she said, standing inside her truck at the end of a recent lunch rush. “The food is good and it’s cheap, so the customers are happy.”

Ramirez was part of a recent experiment to improve the nutrition offered by taco trucks, one of the best known parts of Los Angeles’ dining landscape. That means meals with fewer calories, smaller portion sizes and more fruits, vegetables and whole grains.

The results, which still are being finalized, were not all good. Only about half of the two-dozen truck owners who participated finished out the six-month pilot. Some dropped out because their customers weren’t buying the new meals or because they got too busy.

Doroteo Lopez, 58, a truck owner near UCLA who completed the study, says the meals thrilled some of his customers — others, not so much.

“People like greasy food,” he explained. “They like the flavor.”

Even so, it is important to try to reach the lunch truck crowd, said Deborah Cohen, a senior scientist at the RAND Corp. who led the federally funded project.

“If you can make this work with loncheras,” she said, “you can probably make it work anywhere.”
Many people don’t realize they are increasing their risk of chronic disease every time they eat a plate piled high with fats and carbs, Cohen said. And the lunch trucks – or loncheras – often serve a Latino clientele that already has high rates of diabetes, obesity and other diseases.

The food truck campaign is the latest push in LA County and elsewhere to make it easier for people to eat better. Corner markets are offering more fresh fruits and vegetables. Some restaurants are reducing portion sizes and providing more nutritious children’s meals. Many schools have nixed the sale of sugar-sweetened beverages.

“It seems like a lot of piecemeal things, but that is the approach that’s needed,” said Susan Babey, a senior research scientist at the UCLA Center for Health Policy Research, which isn’t involved in the project. “Any one change isn’t going to reverse the whole epidemic that has accumulated over the past 30 years.”

On a sunny February day, Ramirez’ customer Yael Ross, a 29-year-old teacher,ordered a veggie burrito, minus the cheese and sour cream. Ross loves Mexican food but doesn’t eat meat, so she was thrilled to see vegetarian choices on the menu. She thinks Los Angeles is the perfect place to try out the idea.
“LA has one of those demographics that really care about health and appearance,” she said. “People really do look for the healthier option.”

But let’s face it, folks don’t often head for the lunch truck with health food in mind. Daniel Godwin, 45, says he can’t resist the bacon-wrapped hot dog. “I eat healthy at home,” he said.

Maria Eseo has high cholesterol and tries to watch what she eats. But not today. She ordered the beef combo plate with rice and beans. “It’s awesome,” she said.

Maybe next time, Eseo said, she will make a healthier choice. “At least they are offering them,” she said.

The lunch truck project was launched in Los Angeles County with a grant of $275,000 from the National Institutes of Health. RAND researchers recruited participants through an association of lunch truck owners and by making cold calls to them. There are an estimated 2,580 licensed truck owners in Los Angeles County.

RAND sent out a nutritionist to help design new menu items and show the cooks how to prepare them. Researchers helped publicize the businesses through social media and brochures and promised to pay truck owners $250 for participating. At first, customers could purchase the healthier meals at a discount.
In part, the sales of the healthier plates depended on the truck’s clientele – whether they were corporate foodies, for instance, or recent immigrants.

“The neighborhood where they are parked is important,” said graduate student Ben Colaiaco, one of the researchers. Ramirez says she sells more healthy meals in Koreatown and downtown, where there is a mix of ethnicities rather than just first-generation Latino immigrants.

Lopez, the vendor near UCLA, said students especially like his lighter menu. But the older customers stick to tacos, burritos and quesadillas, especially savoring the marinated pork and beef, he said.

Olga Aguilar, 30, who parks her truck in downtown Los Angeles, worked with a nutritionist to develop two new plates – chicken tacos and carne asada, both served with green beans, carrots, melon and strawberries. The new additions raised some eyebrows among her customers and her competitors.

Nevertheless, they were popular. Aguilar said some of her customers told her that they have high cholesterol and are supposed to eat less grease and less meat. “They tell me the doctor tells them to eat more vegetables,” she said.

On a recent day, Colaiaco came to do a final interview with Ramirez about her experience and to deliver the $250 check for participating.

“What do your clients think of the new plates?” Colaiaco asked.

She said she doesn’t have a lot of time to talk, but nobody had complained. “A lot of people say they are delicious,” she said.

The pilot project is over now, but she isn’t finished yet. She has plans for a tasty new item she never considered before: a veggie burger.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

“Is this doctor in my insurance network?” is part of the litany of questions many people routinely ask when considering whether to see a particular doctor. Unfortunately, in some cases the answer may not be a simple yes or no.

That’s what Hannah Morgan learned when her husband needed surgery last fall to remove his appendix. When they met with the surgeon at the hospital emergency department near their Lexington, Ky., home, Morgan asked whether he was in the provider network for her husband’s individual policy, which he bought on the Kentucky health insurance exchange. The surgeon assured her that he was. When she got home, Morgan confirmed that he was in network using the online provider search tool for her husband’s plan.

But when she read the explanation of benefits form from the insurer, the surgeon’s services were billed at out-of-network rates, leaving the couple on the hook for $747.

The surgeon’s office later told her that he belonged to two different medical groups. One was in Morgan’s husband’s health plan network, the other wasn’t. Following multiple phone conversations with the surgeon’s office and the insurer, the in-network rates were applied and the Morgans’ share of the bill shrunk to $157.

“I did everything I was supposed to do,” says Morgan, 26. “You feel kind of hopeless. I thought I did it right, and there’s still another hoop to jump through.”

Consumers who use out-of-network providers can rack up huge bills, depending on the care required. Health maintenance organizations generally don’t cover any non-emergency services provided by physicians or hospitals outside the plan’s network of providers. Preferred provider organizations typically do cover out-of-network services, but pay a smaller percentage of the charges, 70 percent instead of 80 percent, for example. Out-of-network services may have higher deductibles and higher out-of-pocket maximums as well.

Although it’s not routine, physicians may belong to more than one medical group, say experts. Surgeons, for example, may join a couple of medical groups to expand the number of hospitals that they’re affiliated with.

Even then, sussing out in-network providers may not be straightforward. Just because a medical group is in someone’s provider network, consumers can’t be confident that all the physicians in the medical group are also in network.

“Physician groups can be in network even though individual physicians in that group may not be,” says Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group.

That situation might occur if some of the physicians in a medical group agreed to accept the rates negotiated with an insurer, but others did not, says Dr. Jay Kaplan, an emergency physician who’s president-elect of the American College of Emergency Physicians. The physicians who didn’t accept the network rate would be out-of-network for a patient, even if other members of the medical group were in network.

Consumer advocates say the lack of transparency is unfair to consumers.

“It’s 2015. Federal law requires Americans to buy health insurance,” says Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Mass. “There’s something fundamentally wrong when you can only figure out what questions to ask after the fact.”

In addition to confusion about doctors who are part of more than one practices, consumers may also run into billing troubles if their doctor operates  practices in different locations and accepts different insurance plans at each, say billing experts.

A podiatrist may see patients at one office location two days a week, and at another office location the rest of the week. Each practice may accept different insurance plans, and a patient may be in network only at one location.

If the physician’s office submits the paperwork to the insurer with the tax identification number for the wrong office location, the patient may get hit with an out-of-network charge. In that case, the patient may have to contact the doctor’s staff and ask them to resubmit the charges through the other practice. Generally that should solve the problem, experts agree.

Adding to the confusion is the fact that even if a physician is in a consumer’s insurance network, the hospital or clinic she works at may not be or vice versa. When undergoing a procedure or treatment, the patient could get hit with out-of-network facility and other charges.

More consumers may face out-of-network problems as health plans shrink the size of their provider networks in an effort to keep costs down.

“Health plans work very hard to see that consumers have the information they need and resources to turn to when they have questions,” AHIP’s Pisano said, noting that the Healthcare Financial Management Association and AHIP’s foundation have online guides to help consumers. Still, she added, “There is clearly also a responsibility on the part of providers to be more transparent.”

Consumers such as Morgan shouldn’t have to bear the burden when that is unclear, says Rukavina.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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