Unfair Advantage? United Healthcare Boots Thousands of MDs From Its Part C Medicare Plans

October 28, 2013

MINNETONKA, MN — "United Healthcare (UHC) is amending your Agreement . . . to discontinue your participation in the Medicare Advantage network effective on February 1, 2014," went the letter to Dr Walid Saber (Oceanstate Cardiovascular & Vein Center, Woonsocket, RI) from the largest commercial health insurance carrier in the US.

The October 2, 2013 letter went on to say his termination is "without cause," his contract permits the company to take this action, and his affected patients would be contacted about the change separately. UHC has sent such a letter to thousands of physicians in the US, specifying that the cuts apply only to their Medicare Advantage contract, not to any other UHC plans they may take.

"It's unclear what criteria they are using to keep or dismiss physicians—they're keeping the criteria to themselves," the interventional cardiologist said to heartwire ."We work very hard as physicians to take care of a lot of uninsured people, and for them to start hitting us hard on people who have some insurance, it's just unfair."

According to one estimate, about 95 Rhode Island physicians have been dropped from UHC's Medicare Advantage offerings, the Medicare "Part C" coverage option administered by insurance companies[1]. The company sells such plans nationally through AARP, which calls them AARP MedicareComplete.

UHC tried to assure Saber that other carriers would pick up his patients with their Medicare Advantage coverage or they would switch to other physicians still on their panel. "We have hundreds of [those] patients. How do they know they will be easily absorbed by other physicians they decided to keep?" And, he wonders, "What's to stop other insurance companies from doing this?"

Dr Edward Kosinski (Cardiology Physicians, Fairfield, CT), also an interventionalist, received a similar letter from UHC more than a week ago, along with the 16 other cardiovascular specialists in his practice. About 3000 of their patients are affected, including >500 of his own patients, "people that I've cared for for over 20 years. I'd say that represents 10% to 15% of my practice," he said.

It's unclear what criteria they are using to keep or dismiss physicians—they're keeping the criteria to themselves.

"These are relationships that have been established, and all of a sudden they are terminated in this absolutely irrational way by United Healthcare," Kosinski said. At least some of his affected patients did receive a letter from the company, he said, but many of them don't understand its implications or what recourse they may have.

The company didn't give Kosinski any warning he would be dropped from the plan, and answers to his queries as to why have been "vague," with references to quality of care, costs, and other issues, he said.

A spokesperson for the Yale Medical Group (New Haven, CT), with >1000 physicians who are Yale University School of Medicine faculty, told heartwire that UHC has dropped it from its Medicare Advantage plans.

Replies emailed to heartwire from an UHC spokesperson were not much more specific. Ben Goldstein, who represents the company in Rhode Island, Connecticut, and other states in the US Northeast, said UHC expects its Medicare Advantage network to be 85% to 90% as large as it is now by the end of 2014[2]. He wouldn't specify how the company determined which doctors to cut.

"Our decisions are based on providing a network of physicians whom we can collaborate with to help enhance health plan quality, improve healthcare outcomes, and curb the growth in healthcare costs," he wrote. "Factors include geography and ensuring ready access to care, the relative performance of providers on a range of industry quality metrics, and a provider's ability to deliver high-quality care for the most members in the most cost-efficient manner."

The cuts have been "tailored to the needs of our members at the local level." Regional effects will depend on "the local provider community, the healthcare needs of our members, and our responsibility to provide appropriate access to physicians and specialists," according to Goldstein.

"Specialties of All Makes and Kinds"

In Connecticut, that means the company is slashing 810 primary-care physicians and 1440 subspecialists from its Medicare Advantage plans, making up 19% of the UHC state network, according to Mark Thompson, executive director of the Fairfield County Medical Association.

Patients in need of care who have Medicare Advantage would need to travel to the mainland by ferry or plane, no easy task in bad weather.

The number of affected physicians in the state was as specific as UHC got with him, he told heartwire ." How United Healthcare made this determination, they would not share with us." Based on the practices he knows are affected, "it's not based on specialty—it does appear to be specialties of all makes and kinds—and it's not based on group size."

The company did tell Thompson that its "network realignment initiative" is a nationwide plan and that the cuts are deeper in some other states, including Florida, where 45% of physicians were dropped.

At least 300 of those Florida physicians are from three counties in the state's southwest, Lee, Collier, and Charlotte counties, according to a local news report [3]. The area includes the cities of Fort Myers, Cape Coral, and Naples. The populous Tampa Bay region (primarily Tampa and St Petersburg, FL) was also hit hard[4].

The cuts' impact could be especially hard on patients in remote areas. In an October 22 letter published in the Providence Journal , the director of health services on Block Island, 13 miles off the coast of Rhode Island, reports that all of the tiny island's physicians received one of UHC's termination letters[5].

The island of about 10 square miles with a year-round population of about 1000 is a popular summer destination for tourists. To avoid out-of-network rates, the according to the letter to the editor, "patients in need of care who have Medicare Advantage would need to travel to the mainland by ferry or plane, no easy task in bad weather."

Uncharted Territory

Besides Rhode Island, Connecticut, and Florida, states that he knows are affected include New Jersey, New York, and Indiana, but so far not Texas or the West Coast, according to Dr David May (Texas Health Presbyterian Hospital, Flower Mound), who chairs the American College of Cardiology board of governors.

"We're moving in an area that's uncharted," he said to heartwire . "I've never seen a [health insurance] company cancel this many contracts without cause, in this broad a geography."

According to May, if other insurance carriers with Medicare Advantage plans follow suit and start dropping physicians, then it "questions the viability" of Medicare Advantage as it is currently structured. (The ACC has issued a guidance on the UHC Medicare Advantage changes[6].)

He also hasn't detected a pattern to the kinds of physicians and practices let go. May said his first contact with affected physicians in Florida was with a practice that had received UHC's "Premium Designation," which "recognizes physicians for meeting guidelines for quality and cost efficiency," as the company puts it.

This does not seem to be about quality of care or even utilization. It seems to be much broader than that.

"These are high-performing groups, many of those getting these letters," May said. "This does not seem to be about quality of care or even utilization." Whatever the reason, "I would like to know what the metrics were that drove it. I'm willing to bet that it has to do with the financial side and not the performance side of the practices and providers that they are getting out of the network."

Thompson agrees; he said UHC told his organization that the physician cuts were based on quality, the local size of their physician panels, and "cost of the physician provider to the insurer." But, he said, "these physicians are being dropped only from their Medicare Advantage plan, they're not being dropped from UHC's other product lines. If it were about quality, they'd be dropping them off of everything."

UHC's carefully worded responses to heartwire also mention quality but seemed mostly about money: "The changes we are making to our network are designed to encourage higher-quality healthcare coverage and help keep that coverage affordable for our Medicare plan members in light of the significant [federal] underfunding of Medicare Advantage."

The company's action, it said, "absorbs the cuts to Medicare Advantage plans in a way that is least harmful to members' pocketbooks. We understand that these changes are disruptive to some providers and members, but they were necessary to ensure that our plans remain sustainable for members not just in 2014 but for the long term."

Show Us the Data

Does that mean the company dropped the 2250 Connecticut physicians who were the costliest to them? Then show us the data, Kosinski said, and if they're not cost-effective physicians he has no problem with their being dropped. "But I would have a problem with the transition of care and the rapidity with which it's being done. I would want the transition of care to ensure that patients are not put at risk. And what they are doing now is putting patients at risk."

It's been surprising how few are aware it. These are the elderly: if they receive a letter, I'm not sure it registers completely.

If UHC has indeed notified patients of its plan, "it's been surprising how few are aware it. These are the elderly: if they receive a letter, I'm not sure it registers completely." Kosinski said some of his patients have called him about the matter, and "most of them don't quite understand it."

On top of the confusion, there is UHC's timing in announcing the cuts. "There's a very small window of opportunity for the elderly to switch care," said Kosinski. Medicare open enrollment started October 15 and runs only until December 7. He estimates that over half of the elderly patients in his care will not understand that they now have about six weeks to change carriers in order to keep their doctor. His fear is that most "will be left stranded" because they will hear only that their physician can no longer see them.

"I think it would have worked a lot better if we'd had a year's warning. Many of these people we see every six months, typically," Kosinski said. "They have enough problems taking their medicines. Now they have to change their healthcare plan? Unless there's someone there to do it for them, many of them won't be able to do that."

Perplexed, Frightened, or Both

Thompson said some physicians in Connecticut who have received the ejection letters report that their names remain on UHC's online list of Medicare Advantage physicians. That's very misleading, he said, at a time when anyone shopping for a plan needs to know what physicians are on the company's panel both now and after February 1, 2014, when the cuts take effect.

May agreed; in fact, everyone heartwire spoke to stressed that Medicare Advantage patients, by definition among the most vulnerable of patients, often don't fully understanding the nuances of health insurance coverage, and many will be perplexed, frightened, or both by their notification letter from UHC.

They may think they're losing for good the doctor who knows them and what prescriptions they need, May said. "They might not even go seek their regular follow-up care," and that will especially hurt heart-failure patients, those with implanted devices, and others who might need frequent visits."

Of course, it's not just cardiology affected. Thompson heard from a nephrology group cut by UHC, for example. To stay with the insurance company, the group's patients who need dialysis will have to go to another practice, the closest of which is several hours away through traffic-congested southwest Connecticut, "and that's even if you have transportation to get there."

Just based on these facts alone, it should rescind what they did, take a step back.

Several oncology groups that received the UHC letter have told him that "the word is getting to their patients that their physicians are being dropped," Thompson said. "Imagine for a moment that you have three months to live, and your insurance company is telling you that the physician taking care of you in the last few months of your life can't be your doctor anymore."

According to Kosinski, "This is a patient-care issue. It should not be a business issue with UHC. They are supposed to be involved in insuring healthcare, and from my perspective what they have done is to seriously jeopardize the care of the most vulnerable and sickest population that we have in this state."

Thompson also holds UHC to a special level of accountability. "When they agreed to [offer] a Medicare Advantage plan, they became the steward for a very important public-health program. They're stepping into the shoes of the Medicare program." He called the cuts "unconscionable without first talking with the patient-advocacy groups, and they did not do that." He knows that, he said, because the Connecticut AARP director told him "she knew nothing about this."

The entire effort, he said, "was so poorly handled by United Healthcare that just based on these facts alone, it should rescind what it did, take a step back, talk with public-health officials, medical organizations, and the patient-advocacy groups, and rethink the whole thing."

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