Rural Hospitals Question Whether They Can Afford Medicare Advantage Contracts

This story was originally published by KFF Health News.

Rural hospital leaders are questioning whether they can continue to afford to do business with Medicare Advantage companies, and some say the only way to maintain services and protect patients is to end their contracts with the private insurers.

Medicare Advantage plans pay hospitals lower rates than traditional Medicare, said Jason Merkley, CEO of Brookings Health System in South Dakota. Merkley worried the losses would spark staff layoffs and cuts to patient services. So last year, Brookings Health dropped all four contracts it had with major Medicare Advantage companies.

"I've had lots of discussions with CEOs and executive teams across the country in regard to that," said Merkley, whose health system operates a hospital and clinics in the small city of Brookings and surrounding rural areas.

Merkley and other rural hospital operators in recent years have enumerated a long list of concerns about the publicly funded, privately run health plans. In addition to the reimbursement issue, their complaints include payment delays and a resistance to authorizing patient care.

But rural hospitals abandoning their Medicare Advantage contracts can leave local patients without nearby in-network providers or force them to scramble to switch coverage.

Medicare is the main federal health insurance program for people 65 or older. Participants can enroll in traditional, government-run Medicare or in a Medicare Advantage plan run by a private insurance company.

In 2024, 56% of urban Medicare recipients were enrolled in a private plan, according to a report by the Medicare Payment Advisory Commission, a federal agency that advises Congress. While just 47% of rural recipients enrolled in a private plan, Medicare Advantage has expanded more quickly in rural areas.

In recent years, average Medicare Advantage reimbursements to rural hospitals were about 90% of what traditional Medicare paid, according to a new report from the American Hospital Association. And traditional Medicare already pays hospitals much less than private plans, according to a recent study by Rand Corp., a research nonprofit.

Carrie Cochran-McClain, chief policy officer at the National Rural Health Association, said Medicare Advantage is particularly challenging for small rural facilities designated critical access hospitals. Traditional Medicare pays such hospitals extra, but the private insurance companies aren't required to do so.

"The vast majority of our rural hospitals are not in a position where they can take further cuts to payment," Cochran-McClain said. "There are so many that are just really in a precarious financial spot."

Nearly 200 rural hospitals have ended inpatient services or shuttered since 2005.

Mehmet Oz — doctor, former talk show host, and newly confirmed head of the Centers for Medicare & Medicaid Services — has promoted and worked for the private Medicare industry and called for "Medicare Advantage for all." But during his recent confirmation hearing, he called for more oversight as he acknowledged bipartisan concerns about the plans' cost to taxpayers and their effect on patients.

Cochran-McClain said some Republican lawmakers want to address these issues while supporting Medicare Advantage.

"But I don't think we've seen enough yet to really know what direction that's all going to take," she said.

Medicare Advantage plans can offer lower premiums and out-of-pocket costs for some participants. Nearly all offer extra benefits, such as vision, hearing, and dental coverage. Many also offer perks, such as gym memberships, nutrition services, and allowances for over-the-counter health supplies.

But a recent study in the Health Services Research journal found that rural patients on private plans struggled to access and afford care more often than rural enrollees on traditional Medicare and urban participants in both kinds of plans.

Susan Reilly, a spokesperson for the Better Medicare Alliance, said a recent report published by her group, which promotes Medicare Advantage, found that private plans are more affordable than traditional Medicare for rural beneficiaries. That analysis was conducted by an outside firm and based on a government survey of Medicare recipients.

Reilly also pointed to a study in The American Journal of Managed Care that found the growth of private plans in rural areas from 2008-2019 was associated with increased financial stability for hospitals and a reduced risk of closure.

Merkley said that's not what he's seeing on the ground in rural South Dakota.

He said traditional Medicare reimbursed Brookings Health System 91 cents for every dollar it spent on care in 2023, while Medicare Advantage plans paid 76 cents per dollar spent. He said his staff tried negotiating better contracts with the big Medicare Advantage companies, to no avail.

Patients who remain on private plans that no longer contract with their local hospitals and clinics may face higher prices unless they travel to in-network facilities, which in rural areas can be hours away. Merkley said most patients at Brookings Health switched to traditional Medicare or to regional Medicare Advantage plans that work better with the hospital system.

But switching from private to traditional Medicare can be unaffordable for patients.

That's because in most states, Medigap plans — supplemental plans that help people on traditional Medicare cover out-of-pocket costs — can deny coverage or base their prices on patients' medical history if they switch from a private plan.

Some rural health systems say they no longer work with any Medicare Advantage companies. They include Great Plains Health, which serves parts of rural Nebraska, Kansas, and Colorado, and Kimball Health Services, which is based in two small towns in Nebraska and Wyoming.

Medicare Advantage plans often limit the providers patients can see and require referrals and prior authorization for certain services. Requesting referrals, seeking preauthorization, and appealing denials can delay treatment for patients while adding extra work for doctors and billing staff.

"The unique rural lens on that is that rural providers really tend to be pretty bare-bone shops," Cochran-McClain said. "That kind of administrative burden pulls people away from really being able to focus on providing quality care to their beneficiaries."

Jonathon Green, CEO of Taylor Health Care Group in rural Georgia, said his system had to set up a team to deal solely with coverage denials, mostly from Medicare Advantage companies. He said some plans frequently decline to authorize payments before treatments, refuse to cover services they already approved, and deny payment for care that shouldn't need approval.

In these cases, Green said, the companies argue that the care wasn't appropriate for the patient.

"We hear that term constantly — 'It's not medically necessary,'" he said. "That's the catchall for everything."

Green said Taylor Health Care Group has considered dropping its Medicare Advantage contracts but is keeping them for now.

Cochran-McClain said her group supports policy changes, such as a federal bill that aims to streamline prior authorization while requiring Medicare Advantage companies to share data about the process. The 2024 bill was co-sponsored by more than half of U.S. senators, but needs to be reintroduced this year.

Cochran-McClain said rural-health advocates also want the government to require private plans to pay critical access hospitals and similar rural facilities as much as they would receive from traditional Medicare.

Green and Merkley stressed that they aren't against the concept of private Medicare plans; they just want them to be fairer to rural facilities and patients.

Green said rural and independent hospitals don't have the leverage that urban hospitals and large chains do in negotiations with giant Medicare Advantage companies.

"We just don't have the ability to swing the pendulum enough," he said.

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