If you’re in a Medicare Advantage plan or any health insurance plan that requires you to use in-network health care providers and you have not thought about the fact that you can’t count on your health plan covering those physicians and hospitals over time, you should. In fact, right now, hospitals and physicians are dropping like flies from a large number of health plans. Melanie Evans reports for the Wall Street Journal about the ugly situations patients in these health plans are facing.
One reason to stay away from Medicare Advantage plans–which cover your care from in-network providers only or which cover only some of the cost of your care from out-of-network providers–is that you might end up having to switch physicians mid-course of treatment. That seems to be happening to tens of thousands of people in Medicare Advantage plans and other health plans in the last couple of years. The corporate health insurers offering Medicare Advantage plans too often are denying payments to hospital systems and forcing physicians to go through multiple hoops to get care approved, at enormous cost to them. So, the hospitals and physicians are fighting back, refusing to contract with the insurers.
Lots of patients are hearing from their local hospitals and physicians that their insurance will no longer cover their care from these providers. Hospitals want more money and less headache. They say that insurer prior authorization rules are endangering the health and well-being of their patients.
Patients, in turn, are left in a serious quandary. Stay with their longtime physicians and hospitals and be liable for the full cost of their care, often thousands or tens of thousands of dollars. Or, switch to new hospitals and physicians, which can compromise their health. Moreover, switching care providers is almost always a total headache and challenging in and of itself.
A lot of the problem stems from the fact that unlike other wealthy nations, the US does not set provider rates, we leave it to the health insurers to negotiate them. It’s a recipe for insanity. If providers have a lot of power, the rates can be excessive. If the insurers have all the power, the rates can be so low as to threaten the quality of care.
For example, in Medicare Advantage, insurers can spend less if they don’t contract with cancer centers of excellence. But, the latest research suggests that means patients are likely to get poor quality cancer care and face higher mortality rates.
What’s worse is that our health care system allows insurers offering Medicare Advantage plans and all other health plans the discretion to decide when care is covered. If they’re facing pressure from Wall Street to return greater profits, the insurers can stint on care. The less care they cover, the more money they get to keep and the more they profit.
In January, UnitedHealth ended some in-network coverage from Mount Sinai in New York City. On March 1, UnitedHealth terminated contracts with other Mount Sinai hospitals. As of March 22, it will end coverage for physicians in the Mount Sinai system. UnitedHealth hasn’t been paying Mount Sinai providers as much as providers at other hospital systems.
What can you do if your health care providers leave your insurers’ networks? You have some protection against surprise medical bills. And, your insurer is obligated to have adequate networks, so your insurer might continue to cover your care in order to meet network adequacy requirements. But, this is no way to run a healthcare system if you care at all about patients’ health and well-being.
Here’s more from Just Care:
- Five concerning policy outcomes of Medicare Advantage program
- How to switch to Traditional Medicare from Medicare Advantage?
- New poll confirms serious access to care concerns in Medicare Advantage
- Are lower income individuals enrolling in Medicare Advantage for the wrong reasons, at their peril?
- Take advantage of the Medicare Advantage Open Enrollment period
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