Last fall, patients in at least 11 states across the country were informed that their physicians — including a large number of neurologists — would be dropped from their UnitedHealthcare (UHC) Medicare Advantage plan, an alternative to the traditional Medicare fee-for-service system run by the government that offers medical and drug coverage but restricts members to care provided by physicians in its network. For many patients the notifications arrived close to the re-enrollment deadline, leaving them scrambling to make quick decisions: renew their plan and lock it in for the next year, or change plans so that they could stay with doctors they'd been seeing for years.
While UHC has not provided a clear explanation for its actions, it is assumed that the policy was associated with cost-cutting efforts. For the last four decades, Medicare beneficiaries have been offered the choice of receiving benefits through either traditional Medicare, or private plans — financed by the government, but run by insurance companies (dubbed “Medicare Advantage” plans since 2003). The Advantage plans offer the same basic health coverage benefits as Medicare, but typically offer additional enticements (such as discounts for gym memberships, hearing aids and rides to the doctor) in order to compete for business.
In 2009, the Medicare Payment Advisory Commission (MedPAC), which advises Congress, reported that Medicare paid private insurers 14 percent more per beneficiary than it would have cost the government to cover those beneficiaries in traditional Medicare. According to MedPAC, from 2004 to 2008, the overpayments totaled nearly $44 billion. The result, despite aggressive lobbying by the insurance industry, culminated in a provision in the Affordable Care Act (ACA) to eventually phase out those overpayments — $156 billion over 10 years — and align the costs of the two programs. The ACA also aims to reward private insurers that offer the best care based on quality measures.
UnitedHealthcare has not publically disclosed the exact number of doctors dumped from the plan, but according to a June 2013 Kaiser Family Foundation report, 14.4 million Medicare beneficiaries were enrolled in Medicare Advantage (MA) plans, an increase of more than one million from 2012. In 2013, five firms or affiliates accounted for 63 percent of all enrollees with UnitedHealthcare holding the leading market share — 21 percent or about 3 million enrollees. According to Kaiser, 90 percent percent of UHC enrollees are in zero premium plans — no monthly premium on top of the Medicare fee subtracted from the retiree's social security check. It has been suggested that by terminating numerous physicians from the MA networks, UHC hopes to stem financial losses which will result from reduced federal payments.
NEUROLOGISTS ON THE FRONT LINE
Marina Neystat, MD, who has been practicing neurology in Forest Hills and Brooklyn, NY, for 15 years, described her practice's experience with UHC as disturbingly opaque. On Sept. 27, the group — comprised of two neurologists, two cardiologists, and two physical therapists — received a letter stating that the group would be dropped. When they appealed, the response was addressed only to the physical therapists in the group, stating the decision would be upheld. It was not until the group requested individual responses that they received letters addressed to each provider. Those letters, dated Nov. 7, which upheld the denial decisions, were signed by an unnamed “NQC Appeal Coordinator,” discouraging direct communication.
“I spoke with all my patients and the reaction was worse for those with complex problems including Parkinson's disease, chronic pain, and epilepsy,” Dr. Neystat recalled. “Patients were very upset, and ultimately some wrote their own letters and others switched to other Medicare plans,” she said.
Some believe that this may be exactly the reaction UHC was hoping for. Neurologist Daniel Kantor, MD, past-president of the Florida Society of Neurology, explained that insurance companies want to keep their risk pool beneficial, and this means figuring out ways to make themselves unattractive to people with expensive diseases often needing specialty pharmacy medications. “Neurologists who take care of a lot of multiple sclerosis (MS) patients, for example, were either downgraded to non-preferred status, or dropped outright based on the high cost of MS medications which often exceeds $50,000 per year,” he said. “But it's not that MS doctors were charging more for their services or wasting resources by doing too many tests; rather, the nature of treating patients with the condition is that medications are expensive and they need a lot of MRI scans.” Indeed, when some of those same specialists inquired about their ratings on other quality measures, they were told that they scored extremely high, he said.
Norwich, CT, Neurologist Anthony G. Alessi, MD, chair of the AAN Sports Neurology Section, was one of the first neurologists notified of being cut from the plan. He recalls being at an Academy meeting of the committee on sections, when his office informed him. “No one likes to be cut from a program, especially when no cause is given,” Dr. Alessi said. “I was outraged that UnitedHealthcare could end long relationships I had with elderly patients and not provide a reason.” But he was more fortunate than most, because the retirees from General Dynamics, a large employer in his area, were excluded and did not receive letters from UHC. They still are on UHC MA and he can bill the plan for their services.
Although Bristol, RI, Neurologist and Co-chair of the AAN Government Relations Committee Elaine C. Jones, MD, was not dropped, she was notified of the crisis in September in her role as president of the Rhode Island Medical Society. “They didn't just drop specialists, they also got rid of primary care doctors including all of those who work on Block Island, a one-hour ferry ride to the mainland,” she said. During a subsequent meeting with UHC, executives explained that while they did geographical assessments for access, their software didn't specify whether the distance was land or water. (They did eventually add this group back on appeal.)
“Many of our providers have now gone through the appeal process, and the only thing UHC wanted to discuss was whether the notification process was properly followed based on contractual requirements; they did not want to discuss provider quality, cost, specialization or provide any reasons for their termination decisions,” said Dr. Jones. “Nevertheless, the Rhode Island Medical Society learned who was eliminated and who was not, and some patterns emerged: some groups were higher cost providers, for example, groups who offered infusion services, and many were not on electronic health record systems yet,” Dr. Jones observed. After many provider appeals were denied, the Rhode Island Department of Health met with the director of the Office of the Health Insurance Commissioner and the state attorney general, who explained that since the United MA is a federal program, they have no jurisdiction. “But when we called our legislators, they said that it's not legislative, it's regulatory [that is, an issue for the Centers for Medicare and Medicaid Services (CMS)],” said Dr. Jones. “Finally, two senators and two congressmen all signed a letter to CMS and asked them to investigate.”
A PENDING LEGAL DECISION
Connecticut medical societies sought stronger recourse. On Nov. 6, 2013, the Fairfield County Medical Association and the Hartford County Medical Association sued UHC and won a temporary restraining order and a preliminary injunction on Dec. 5, which halted UHC from cutting the associations' doctors from its network on Feb. 1. Another lawsuit is pending in New York. Eighty-two physician associations across the nation — including the AAN — wrote a letter to CMS urging the agency to take immediate action to address the “lack of transparency on network adequacy and physician due process.” (As this story goes to press, the US Court of Appeal for the Second Circuit is hearing arguments in this case.)
According to a Dec. 12 Hartford Courant article, UHC has said the cuts were needed to maintain a quality network at rates that people could afford, but the Fairfield County Medical Association has alleged that the insurer is cutting the doctors who have the sickest, most expensive patients. The article reported that Douglas J. Edwards, associate regional administrator for the CMS, wrote in a letter to the Connecticut State Attorney General George Jepsen, that the agency did ask UHC to describe how their reduced network accounts for people with special needs, and the standards for a patient's travel time, travel distance and the number of doctors did not take into account people who are disabled, elderly, poor, without personal transportation, or do not speak English.
Dr. Kantor suspects that neurologic patients seem to have been unfairly targeted by UHC's actions. “Some patients in Florida now have to cross county lines to see their doctor, a service paratransit does not support,” he pointed out. The decision also has had an impact on non-English speaking patients, he observed. “In Ocala, FL, there were four Spanish-speaking neurologists and three of them were downgraded to non-preferred status by UHC,” he said. “This means that instead of waiting three months for an appointment, they may need to wait 12 months.”
That's little comfort for patients across the country who now have to find ways to identify new providers and the means of transportation by which to reach their offices. Michelle A. Ferreira, DO, a bilingual neurologist and movement disorder specialist practicing in Boca Raton, said her patients were notified in September. Although her group of three neurologists and one physiatrist wrote to contest the decision, their appeal was denied on Oct. 10.
“Many of the patients affected were in their eighties and nineties, and have chronic conditions affecting their mobility such as Parkinson's disease, strokes, and spinal cord injuries; others have dementia,” she said. “They now need to travel 30 to 45 minutes to see another neurologist, and are quite distraught,” she observed, adding, “We had several patients who left in tears when they came to pick up their records.”
Meanwhile, neurologists in Connecticut — and around the country — will be watching for a decision from this test case now before the Second Circuit Court to set a different course.