"Attention: Your doctor(s) will not be in your plan's network starting Jan. 1, 2014."
So reads the opening statement of a Sept. 24 notice received by a Florida woman who for many years had her health care needs attended to by Jack Matheny, M.D., a solo family physician in Palatka, Fla.
Matheny is one of potentially thousands of physicians in multiple specialties and multiple states, including Ohio, Rhode Island, Florida and Connecticut, who have been caught up in UnitedHealthcare's (UHC's) efforts to downsize its Medicare Advantage physician networks.
According to Matheny, the rural health clinic he opened in 1989 serves very poor Floridians. He estimated that about 60 of his elderly patients -- many in their 80s and 90s -- had received notices directing them to choose a new physician.
Patient reactions have ranged from shock to defiance, said Matheny. "Some have said, 'I'll go ahead and switch, but I'll keep you as my doctor,' even though I know they can't afford to do that."
The Florida AFP addressed the issue in its Oct. 23 newsletter to family physicians. "While there is little that can be done to fight the arbitrary cancellations, physicians can advise their patients to switch to a plan where their physician is participating," said the article.
- Less than two months ago, UnitedHealthcare (UHC) began sending out termination notices to a number of physicians in its Medicare Advantage plan networks in multiple states.
- Physicians and their patients were blindsided by the notices, and patients have had to make last-minute choices when selecting their Medicare physicians for 2014.
- At least one state attorney general is investigating, and member organizations such as the AAFP have chided UHC for sending out the notices just as patients were due to complete their 2014 Medicare enrollment.
Matheny took that advice to heart. "When patients come in with the (UHC) letter saying, 'I'm not on that plan anymore,' I hand them a letter advising them that there may be a similar health plan through Blue Cross that would allow them to continue to see me as their doctor," he said.
AAFP Points Out Poor Timing
According to UHC Vice President of Communications Terence O'Hara, UHC is trimming its Medicare Advantage physician network "to encourage higher quality health coverage that people can afford." He said the changes were necessary "to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts."
About $200 billion in funding was cut from Medicare Advantage as part of the Patient Protection and Affordable Care Act.
"By the end of 2014, our Medicare Advantage network of participating physicians and specialists nationally will be between 85 percent and 90 percent of its current size," said O'Hara. He couldn't specify the percentage of cuts made in particular specialties, however. "We evaluate the issues individually, and in some circumstances, additional review of local markets and individual provider concerns has led us to reverse a decision to terminate a provider," he said.
Keeping in mind that Medicare's open enrollment period runs from Oct. 15 to Dec. 7, AAFP President-elect Robert Wergin, M.D., of Milford, Neb., chided UHC for its poor timing in a Nov. 7 AAFP Leader Voices Blog post.
"Regardless of whether UHC's business decision was good for the insurer, it was poorly timed, catching physicians and patients off guard during a critical time of year," wrote Wergin. The blog appeared just one week after top UHC executives met with AAFP leaders and staff members at Academy headquarters in Leawood, Kan., for what has become an annual face-to-face visit designed to discuss member concerns.
Legal Issues Prevail
Florida chapter EVP Jay Millson said he had communicated with a handful of members, all of whom were in private practice. "I suspect it has impacted a significant number of those physicians, but we also have a high penetration of employed physicians who have had their hands tied due to contracts with a hospital or health systems," he said.
The Florida Medical Association recently notified members of the Florida congressional delegation about UHC's actions. "Although these terminations are occurring throughout the country, they are particularly troubling in Florida because of our large population of elderly residents who rely on Medicare Advantage plans for their medical care," said the letter.
"Federal law provides that Medicare Advantage programs 'maintain and monitor a network of appropriate providers … that is sufficient to provide adequate access to covered services to meet the needs of the population served,'" said the letter. "The actions being taken by United appear to be in conflict with these federal requirements."
The association requested that Florida's congressional delegation ask CMS "to initiate an investigation on the impact UHC's decision will have on Florida's Medicare recipients" to ensure that patients would continue to have access to an adequate pool of physicians from which to choose and that those physicians would have the appropriate expertise to treat patients' health care concerns.
In Connecticut, Attorney General George Jepsen called on federal regulators to examine UHC's decision to terminate a large number of physicians from the state's Medicare Advantage network. In a Nov. 6 letter to an HHS regional director in Boston(www.ct.gov), Jepsen said he was concerned about UHC's lack of responsiveness to earlier questions about the scope of terminations and its impact on patients.
"We are deeply troubled by United insisting that its remaining provider network will be adequate despite simultaneously claiming not to know the number of patients affected," said Jepsen. He asked federal regulators to "aggressively scrutinize" United's network to ensure its adequacy and to extend the Medicare Advantage open enrollment period for affected patients to give them more time to make decisions about their care.
Physicians, Patients Deal With Consequences
Ross Winakor, M.D., of Storrs Mansfield, Conn., the immediate past president of the Connecticut AFP, said many issues were at play, including a lack of transparency and no clear criteria as to why physicians were dropped. He said the termination notices affected practices of all sizes in all parts of his state.
Winakor estimated that the state had about 500 family physicians. "I've heard a significant number of stories from members, and my guess is that about 25 to 30 percent of Connecticut's family physicians are affected by this," he said.
UHC's network changes affect a very small percentage of patients in Winakor's four-physician practice. "But even if you only have five patients affected, it's enough to frustrate those five patients," said Winakor. "These patients (getting notices) are 65-plus, and some are physically and cognitively challenged and having to make big decisions very quickly."
The elderly, in particular, often are very distressed with the prospect of changing doctors, said Wergin. "Relationships are important and affect outcomes. Perhaps UHC should survey their employees' and leadership's parents and see how their satisfaction would be with changing doctors after knowing them for some time."
Rhode Island AFP President Roanne Osborne-Gaskin, M.D., M.B.A., of Warwick, said family physicians dropped in her state "were told they weren't being dropped because of any disciplinary issue -- they were in good standing. But there was no other explanation given."
Osborne-Gaskin noted the irony of UHC advertising its Medicare Advantage product in TV ads right up to a month before termination notices began to go out, all the while claiming that patients would be able to keep their physicians.
Ohio AFP President Jon Seager, M.D., of Hartville, said it wasn't the first time -- and it wouldn't be the last -- that physicians and their patients would be affected by insurance company decisions.
"This is what happens when big companies make small decisions; it's an asymmetric relationship. An insurance company can mold and modify its provider panel, and it feels to them to be insignificant because the company has enough docs to cover the lives under that plan. But it has real impacts for the people who want to continue to see their physicians," said Seager.
He recalled a similar situation that occurred with another carrier just a couple of years ago where patients were forced to change their primary care physicians. "For a year or two, patients tried to use a different system and different providers, but for whatever reason, that relationship isn't there."
Now, the practice is getting calls from those patients asking to come back.
"People are upset that they had to leave, and now they're upset that they can't come back," said Seager. "We struggle with it. I want to say 'Yes, I miss you. I'm sorry you haven't had an appropriate primary care experience elsewhere.'
"It's our nature to try and make it right. The problem is we can't fix that now. With burgeoning patient panels, we're working hard to keep up with what patient-centered care demands and patients deserve," said Seager.