Shifting Medicare Advantage Landscape Unsettles Patients
By Matthew Sturdevant, The Hartford Courant | |
McClatchy-Tribune Information Services |
He has end-stage renal disease, meaning his kidneys no longer function at the level needed for day-to-day life.
To qualify for a transplant and make sure he was healthy enough for the surgery, Buccieri said, he had to have a colonoscopy, electrocardiograms and a whole series of tests. He still needs to lose some weight before the procedure, but he laid the groundwork to have the transplant at
Then he got word of a change to his health insurance plan.
Last fall, his insurer, UnitedHealthcare, mailed Buccieri letters telling him that some of his doctors would be cut from its
"It turned my world upside down ... to get the letter that I can't use my nephrologist," he said. "I think he, along with my primary doctor, basically saved my life and stabilized me from declining more than I am now."
Not only were individual doctors ousted, but the entire hospital is leaving the network. Customer-service representatives assured Buccieri over the phone that his kidney procedure would be covered at in-network rates. But the letters said some of his doctors would no longer be in his insurer's network.
The network cuts were UnitedHealthcare's reaction to a major overhaul of
Most people use traditional
The funding changes squeeze insurer profits, and resulting business decisions will continue to make waves in the health care industry for years to come.
Health insurers generally contend with lower federal payments by reducing benefits offered in the
In other words, as time goes on, there is likely to be an increasing number of people like Buccieri, buffeted by changes to a network they have come to depend on but have little or no control over.
"I think you're going to see more of what United is doing, which is trying to do things to limit their costs, and that would be narrower networks for sure," said
"The narrower your network, who is going to care about a really narrow network? People who are sicker," Cogan said. "That's another way to advantageously select from the population. If you're 65 and you've got very little wrong with you, you don't care about a narrower network. You don't care at all."
In February, the
Untold numbers of patients are already contending with UnitedHealthcare's network changes taking place in
Last fall,
"More focused provider networks help deal with the financial pressures created by severe cutbacks in funding of
UnitedHealthcare's notices led to vocal protests by doctors and a federal lawsuit against the company, drawing national attention.
The upheaval may change federal rules about how much notice insurance companies have to give patients before reducing physician networks. UnitedHealthcare started sending out letters to doctors and patients in October; the enrollment deadline for
Last month, the federal
Meanwhile, as the size of the networks is being cut back, the best way for a customer to learn if he is covered for a medical procedure is to call the health plan, UnitedHealthcare spokesman
In Buccieri's case, UnitedHealthcare says there was a misunderstanding. As a "medically necessary procedure," Buccieri's transplant will be covered, O'Hara said.
"Our transplant services are run through a separate network," O'Hara said. "So, if you need a transplant, we have what we call 'centers of excellence' ... for that particular type of transplant. In this case,
In addition to cutting its physician network for
Patients in any health plan,
Hospitals are consolidating at an increasing rate, in part to command better terms from insurance companies. When a large hospital system squares off against a large health insurer, the two are less likely to give in on terms.
In February,
UnitedHealthcare spokeswoman
"We negotiated in good faith with
UnitedHealthcare was able to reach an agreement only with
When UnitedHealthcare announced it would shrink its network, many wondered if the remaining list of doctors was sufficient. All insurers that offer
In response, the agency said it was.
"Our review of the anticipated provider network in
"We have reviewed the report from United[Healthcare] and after much discussion we have determined that the health plan's network exceeds the requirements for minimum number and maximum time/distance."
In other words, the network has enough doctors and none of them are too far a drive for UnitedHealthcare's customers.
"The rules they have are very loose,"
If a person has cataracts or macular degeneration -- as some of Thornquist's elderly patients do -- they often rely on someone else to drive them to doctor appointments. So, if the local ophthalmologist is eliminated from an insurer's
"Let's suppose you have bilateral macular degeneration and your vision in your good eye is 20-80. By law, you cannot drive in this state," Thornquist said.
It's not uncommon his patients have conditions that render them unable to drive.
"Then you must have someone drive you -- either a senior van, or a relative, or a friend, or someone," Thornquist said. "And those rides get harder to get the farther you go."
Reluctantly Staying Put
Patients have expressed anger at UnitedHealthcare for the network changes, at the federal government for allowing them, and at
He is among those upset with the federal
"The decision to eliminate providers was one made by UnitedHealthcare.
"Through
It's still not completely clear to Silverman which doctors are in or out of UnitedHealthcare's network.
"If you looked at their directory of doctors, first of all it's never up to date," Silverman said. "It's the worst damn thing. They send you a directory and you still don't know if they're in there or not."
He said he thinks the online directory is very difficult to use.
This is the last year, Silverman said, that he and his wife will be UnitedHealthcare customers. They plan to switch.
The downside to traditional
People who support the reductions in
'They Made It So Difficult'
Silverman was among more than a dozen people who gathered recently in
The
Before re-enrolling with UnitedHealthcare last fall, Cervero, 68, asked the insurer for a list of changes to the
There wasn't enough time to adequately research and compare the
"I am appalled by the fact that they sent those letters so late, that they made it so difficult," Cervero said. "I'm sorry, but seniors, and I'm one, slow down when we get older. Things that are complicated are longer to unravel."
Cervero chose to continue with a
Cervero has multiple chronic conditions that include a bulging disc in her back and thyroid problems that require medication. But the lesser doctor network means she may have to drive farther for specialty care in her rusting Saturn with about 255,000 miles.
"I like the car," she said, "and I can't afford another one."
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