United Healthcare’s decision to drop hundreds of physicians from its Medicare Advantage plan during the current Medicare open enrollment period has created panic among senior citizens at more than a dozen practices across the state and will force thousands of policyholders to switch plans if they want to keep their doctors, those closest to the situation say.
“To tell people during the fall open enrollment period that all of a sudden all these doctors are no longer going to be able to provide care for them (with their current insurance) is disrespectful to senior citizens and very upsetting,” said Dr. Rick Nedelman of Surgical Associates of Springfield, which handles 70 percent of all general surgical procedures performed in the area as well as follow-up care. “I see patients who are very scared and upset, and, in my opinion, have been done an injustice by United Healthcare.”
Like many of his colleagues, Nedelman appealed the health insurer’s decision to drop him from their network, but the company had yet to reach a decision by the end of last week.
“I’ve instructed my staff to contact UHC every week about where we stand,” he said. “There doesn’t seem to be any rhyme or reason to what they’re doing. They won’t even tell us what the criteria is they’re using in determining which doctors to drop.”
The Ohio State Medical Association has asked the Centers for Medicare and Medicaid Services to launch a formal investigation to determine whether the Minnesota-based health insurer’s move to shrink its provider network will compromise coverage for seniors who rely on many of the doctors being dropped from its network.
Private insurers contract with CMS to provide Medicare Advantage plans and are required to maintain “adequate” doctor networks to serve policyholders in the area, said Todd Baker, director of professional relations with the state medical association.
“We’re taking the fight to CMS to see if we can challenge (United Healthcare’s) network adequacy, and see if we can get physicians added back to the network,” Baker said.
The medical association has reached out to lawmakers in Congress, including House Speaker John Boehner of West Chester Twp., as well as members of the Ohio General Assembly to push CMS to “expedite” its investigation. The open-enrollment deadline for Medicare is Dec. 7, giving seniors less than two weeks to decide whether to enroll in new Medicare plans.
“We’ve already heard back from Boehner’s office and others that they are interested in working on our behalf,” Baker said. “We want to make sure CMS understands the magnitude and timing of this.”
Rising quality standards
United Healthcare, which said it has 102,000 individual Medicare members in Ohio, declined to release details about how many providers it was terminating or the location of the practices that would be affected. But the state medical association compiled a list of 18 practices representing at least 200 doctors who have received termination notices from United Healthcare and included the list in its letter to CMS requesting the investigation.
The health insurer said in a statement that it was narrowing its provider network in response to cuts in reimbursements to Medicare Advantage called for under the Patient Protection and Affordable Care Act.
Before the law was enacted, Medicare Advantage — an alternative to regular Medicare that charges a premium but typically combines hospital, doctor and prescription drug coverage in one plan — was reimbursed by the federal government at 114 percent of regular Medicare rates.
But those payments are being reduced over time to the same level as traditional Medicare by 2017, resulting in more than $100 billion in cuts over the next several years. In addition, starting next year, the government will limit Medicare Advantage profit and overhead to 15 percent of revenue, requiring at least 85 percent to be spent on care.
“Many Medicare Advantage plans, including United Healthcare, are making changes to their networks to improve the quality and affordability of health care coverage for their customers,” the statement reads. “While these changes can be difficult for patients and their doctors, they are necessary to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts.”
Dr. Lawrence Mieczkowski, an internal medicine doctor in Kettering was notified about a month ago that he was being dropped from the health insurer’s network, affecting about 80 of his patients, many of whom suffer from chronic conditions such as diabetes and kidney disease and need constant monitoring and regular treatments.
Mieczkowski appealed his termination on the grounds that it would disrupt critical care for his patients who would be hard-pressed to quickly find another doctor. But he described the appeals process as a “total waste of time.”
“I had a teleconference with them that was supposed to last 30 minutes. It lasted four or five minutes. There weren’t even any local doctors involved. They were all from out of town and didn’t have anything to do with the Dayton market. They didn’t even ask any questions,” Mieczkowski said.
He said he thinks the health insurer has little interest in hearing appeals because terminating select doctors is a key part of the company’s strategy to blunt the impact of Medicare Advantage cuts.
“They (insurers) are going to try to reduce those losses, and there are really only two strategies to do that: pull out of the market or kick their most expensive patients off their plans,” Mieczkowski said. “By not renewing certain doctors as part of their network, they’re getting high-cost patients to go to other insurance plans and cutting their losses.”
Mieczkowski accused United Healthcare of “cherry picking” doctors and terminating mainly those with the highest-cost patients who often see specialists: “Most of what I’m hearing is that the specialists’ offices are not getting contracts renewed. I haven’t heard of any family practices not having their contracts renewed.”
At least 37 physicians at the two largest gastroenterology practices in the Dayton area received termination notices from United Healthcare, and at least 50 doctors in Clark County have received termination letters, according to the medical association, which said practices throughout southwest Ohio have been affected.
Donald Mackos, president of Dayton-based MB Senior Solutions, an insurance broker that specializes in Medicare plan selection, said most Medicare Advantage policyholders can continue to see their doctors if they spend the time and take the due diligence to research other plans that include their doctors in their networks.
But Mackos acknowledged the challenges facing seniors who may have trouble navigating the complex health insurance industry or have limited access to computers. And the prospect is already causing great consternation for thousands of area seniors, about half of whom are enrolled in Medicare Advantage plans in Montgomery County alone, Mackos said.
“Of the 20,000 area seniors we serve, we will recommend a plan change for about 5,000 of them,” because of United Healthcare’s actions, Mackos said. “There will continue to be some very good plans in the area, and they can still find their doctor if they switch to a different plan. But they’re really gong to have to review their needs because these plans will include different costs and benefits. We know seniors don’t like change, but it’s going to be incumbent on them to review their plans and find the plan that’s right for them.”
Incentives drive terminations
Mackos said he expects other large insurers to continue the trend set by United Healthcare, largely because of incentives built in to the health care law. Medicare Advantage plans can now receive bonus payments if they receive a quality rating of 4 stars or better from CMS, based on a 5-star scale. And it’s easier to control quality and with a smaller, more cost-efficient provider network, he said.
“Some experts think the only margin they (Medicare Advantage insurers) will get is what they get from their bonus payments,” said Mackos, noting that most plans in the Dayton area are rated at 3 or 3.5 stars. “So a lot of people are making changes to enhance their overall rating. Each plan is going about it differently, but you will continue to see plans drop doctors to improve their overall quality rating.”