Patients upset, employers scramble as Springfield Clinic poised to exit Blue Cross network [The State Journal-Register, Springfield, Ill.]

Nov. 12—Heidi Young says she has been "100% happy" with her family's doctors and other health care providers at Springfield Clinic for more than 20 years.

That's why she and her husband are so upset and disappointed. It looks like they will have to leave the clinic after Tuesday because of a contractual dispute unresolved for months between the for-profit clinic and the state's largest insurance company, Chicago-based Blue Cross and Blue Shield of Illinois.

"I think it's a perfect example of the almighty dollar getting in the way of what's important," said Young, 50, a Springfield resident and technology industry professional. "I absolutely hate the situation."

Beginning Wednesday, services from the clinic's doctors, nurse practitioners, physician assistants and other professionals will be considered out-of-network for patients insured through Blue Cross and Blue Shield preferred-provider plans.

It doesn't appear the dispute between the two groups is going to be resolved anytime soon. The disagreements came to light earlier this year after almost three decades of a business relationship.

The standoff, affecting tens of thousands of patients throughout central Illinois, will be the largest disruption of health coverage in the Springfield area in recent memory if not resolved.

There will be emotional turmoil for patients, as well as potential for gaps in care that could affect patients' health, according to Andrew Novaria, a health insurance broker at American Central Insurance Services in Springfield.

"People don't want to go to a new barber to get a haircut, let alone get a new doctor," he said.

It's unclear how many employers in the area have taken or will take steps to change health insurance carriers that still classify the clinic as an in-network provider, but Novaria said some have switched.

When the dispute began in the spring, Springfield Clinic estimated more than 100,000 people, or about 20% of the clinic's patients, could be affected, clinic spokesman Zach Kerker said in a written statement.

"But since then, that number has decreased significantly as we have seen scores of employers and thousands of patients make accommodations or switch insurance carriers to stay in-network with our providers," he said.

Blue Cross plans tend to be more affordable than other carriers for employers with more than 50 workers, and some regional and national employers offer Blue Cross plans because they can work well for employees in multiple locales, Novaria said.

Patients insured through Blue Cross PPO plans who continue to use the clinic could face thousands of dollars in additional out-of-network charges.

Those patients also could be "balance billed" by clinic providers who no longer would be required to accept only the amount Blue Cross pays for services.

Many longtime Springfield Clinic clinic patients who lack the option of switching insurance plans to maintain in-network coverage will delay moving to another provider in hopes of a contract resolution, Novaria said.

While waiting, those patients may put off regular visits with their clinic doctors to avoid out-of-network charges they can't afford to pay — a situation he said could lead to health complications.

"I think a lot of people are holding out hope," Novaria said.

The issues

Kerker said Thursday the clinic doesn't expect a resolution by Nov. 17. He didn't elaborate.

Blue Cross spokeswoman Colleen Miller said in a written response to questions from The State Journal-Register, "We continue to hope that Springfield Clinic desires, as we do, to reach an agreement that will mutually benefit our members — their patients — by Nov. 17."

Blue Cross officials sent the clinic a "comprehensive proposal" on June 29 and "have consistently reached out hoping to elicit concrete, specific feedback, including specific asks or detailed concerns for active discussion and negotiation," she said.

Kerker responded, "Springfield Clinic has approached this entire situation in good faith, but we wouldn't need to be advocating for our ability to continue to care for our patients if BCBSIL had not unilaterally terminated us from the PPO agreement."

When asked to detail frictions in the dispute, Kerker pointed to quality care in rural communities and competitive rates.

"We are focused on the needs of our patients, particularly those in rural communities where their options for comprehensive, high-quality care continue to deteriorate," he said in an email. "We are seeking market-competitive rates and fair business terms to continue that mission."

Miller wouldn't say how many employers with Blue Cross coverage have left for other carriers to retain in-network access to Springfield Clinic doctors.

"Overall, we have received much support from our members and employer groups who understand that we're negotiating for value — access, quality and affordability — on their behalf, and our members' behalf," she said.

Springfield Clinic, in written communications with patients, has criticized the "record profits" earned by Blue Cross' parent company during the COVID-19 pandemic.

The clinic, which is privately held, hasn't provided information on its own revenues and profits.

Blue Cross responded generally to the clinic's calls for competitive rates and fair business terms in a Sept. 9 update on its website.

"We do everything in our power to stand with our members in sickness and in health," the post says. "When we look at the health care landscape in Illinois, we see that central Illinois has some of the highest prices for health care in the state. In fact, the cost of living in Springfield is 5% below the national average, while Chicago is 23% above. Yet, health care in Springfield is 16% more expensive than in Chicago! This is not sustainable for our members and local businesses.

"Any demand for artificial, above-market reimbursement rates in the middle of a global pandemic drive(s) up the cost of care for everyone, including our members and employer groups," the post says.

Memorial, SIU pick up patients

Even though Springfield Clinic offers more doctors in certain specialties, such as women's health, than other local physician groups, Miller refuted the notion that Blue Cross lacks in-network providers to make up for the loss of the clinic.

"We offer a network of more than 3,000 in-network doctors and health care professionals in the central Illinois region," she said. "Based on our outreach to network providers, they have expressed access and availability for new patients.

"Additionally, members with a health plan that provides coverage for services provided at out-of-network providers can choose to get care anywhere they want, including Springfield Clinic if we are not able to come to an agreement before Nov. 17," Miller said. "However, their out-of-pocket costs may be higher."

Memorial Health, which has a primary care physician group in Blue Cross' network, and Southern Illinois University School of Medicine, which operates a multi-specialty physician group in the network, both said they have enough capacity to serve patients leaving the clinic.

SIU has received thousands of such requests in the last 60 days, SIU Medicine spokeswoman Rikeesha Phelon said.

Blue Cross can temporarily extend in-network, "continuity-of-care" benefits to members with a life-threatening or "serious acute condition" or if they are in the third trimester of pregnancy, Miller said.

"We are already working with members to transition or continue their care," she said.

Miller noted that Illinois insurance laws protect "fully-insured" patients from incurring higher out-of-network charges in situations when an out-of-network doctor at an in-network hospital provides services to them.

Such situations could involve a out-of-network radiologist, anesthesiologist, pathologist, emergency physician or neonatologist, she said.

For members of self-insured and other plans, federal laws provide financial protections for emergency services performed by out-of-network providers, Miller said.

Stuck in the middle

Christopher Caudle, 49, a Springfield resident and customer service manager for Mel-O-Cream Donuts International, said he and his wife, Tiffani, may have to move from their Springfield Clinic specialty doctors.

The couple may postpone check-ups and "kick the can down the road" in hopes that the two sides work out their differences in the next six to 12 months, he said.

"They're going to upset a lot of people in this town, and it's all about money," Caudle said. "I thought their patients would mean more to them than that. They're slinging the mud to make somebody look like the bad guy, and they're both the bad guy, and it's the patient who's being hurt."

Mel-O-Cream has decided to stick with Blue Cross "at least at this point" even though "we're not very happy about" the situation, Mel-O-Cream human resources director David Ryan said.

When asked about the stress the dispute is putting on patients, Springfield Clinic chief executive officer Ray Williams directed his comments toward the insurance industry.

"Insurance companies view physicians as a commodity," Williams said in a written statement. "We have spent 82 years caring for our communities, and in many cases, we have generational relationships with our patients. Those relationships matter in producing quality outcomes. Our relationships with our patients are not a commodity."

A spokeswoman for Springfield School District 186, which covers its employees through Blue Cross, didn't respond to questions about the district's next move. Officials said in August that it planned to solicit proposals from other insurance carriers.

Williamsville-Sherman School District 15 looked into switching away from Blue Cross but decided it made more financial sense to stay, Superintendent Tip Reedy said.

"Everybody just hopes that Springfield Clinic will get in the same sandbox with Blue Cross and settle," he said.

The Athens and Jacksonville school districts decided to switch from Blue Cross to PPOs provided by Health Alliance and UnitedHealthcare, respectively, so their employees can retain in-network access to Springfield Clinic.

Athens District 213 employees will end up paying about $50 more per month in premiums for Health Alliance single coverage that began Oct. 1. They used to pay $110 per month for Blue Cross coverage, Superintendent Scott Laird said.

Retaining Blue Cross would have cost them $30 per month more, he said.

Jacksonville District 117 employees voted for the UnitedHealthcare option over plans from Blue Cross and two other carriers, Superintendent Steve Ptacek said.

All of the bids came with premiums lower than the previous Blue Cross contract that ended Oct. 1. The cost to employees between the UnitedHealthcare and Blue Cross bids were relatively equal, Ptacek said.

Many employees of the Jacksonville district use the Springfield Clinic primary care and specialty doctors who work out of a building owned by Memorial Health next to Jacksonville Memorial Hospital, Ptacek said.

Auburn resident Jamie Kuhlmann, chief financial officer of Springfield-based Prairie State Bank and Trust, said her employer decided to switch from Blue Cross to Health Alliance, effective Dec. 1, so employees could retain the clinic as an in-network provider.

That was a relief to Kuhlmann, 42, who uses clinic doctors. But her husband, who gets his insurance through his employer, a regional company, doesn't have that option because his employer isn't leaving Blue Cross.

Kuhlmann's husband's primary care doctor isn't at Springfield Clinic, but the pediatrician serving the couple's two children is at the clinic. The children are insured through Kuhlmann's husband's plan because she said that plan is the most affordable.

For now, she said, the children will keep their pediatrician, and the couple will hope their children, who are healthy, don't incur big out-of-network charges.

"We're just going to take our chances," she said.

Kuhlmann said she and her husband hope that the clinic and Blue Cross can come to an agreement eventually.

Heidi Young, as well as her 60-year-old husband and their 13-year-old son, don't have any immediate options for switching from Blue Cross to another insurance carrier through the couple's employer-based insurance plans.

Nor do they have the wealth to risk out-of-network charges even though they are grateful for, and value, the relationships they've built with Springfield Clinic primary care doctors, nurse practitioners, colon surgeons and other specialists.

Young said her family is not alone.

"Everyone I talk to is being impacted by this issue," she said. "Some are putting it off, and others are on the hunt for a new physician."

The family is trying to establish new relationships with primary care doctors at Memorial Care, which is part of the Memorial Health system that operates Springfield Memorial Hospital.

Young said she still has to make arrangements for her family to set up relationships with other medical specialists not offered by Memorial Care.

She said she doesn't blame Memorial, the prospect of leaving Springfield Clinic is a "huge hassle" for her family.

"Twenty years is a long time to be with a provider," she said. "They're definitely a trusted resource."

Young said she blames both Springfield Clinic and Blue Cross for the turmoil.

"You would think that the two organizations would get to some agreement," she said.

"Truly, we're the ones stuck in the middle while they're bickering over the dollar," Young said. "Both organizations don't look favorable at all. It shouldn't get like this."

Contact Dean Olsen: [email protected]; (217) 836-1068; twitter.com/DeanOlsenSJR.

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