Citing concerns related to patient care, access and affordability, St. Charles Health System is evaluating its participation in all Medicare Advantage plans, including those from Humana, PacificSource, HealthNet and WellCare.
St. Charles continues to accept original (or traditional) Medicare, which is funded and operated by the federal government. Medicare Advantage plans are funded by the government but run by private insurance companies.
Dr. Steve Gordon, President and CEO of St. Charles, explains that great thought went into the decision to reevaluate Medicare Advantage participation, and it was done only after years of concerns piled up not just at St. Charles, but at health systems throughout the country. “The reality of Medicare Advantage in Central Oregon is that it just hasn’t lived up to the promise. A program intended to promote seamless and higher quality care has instead become a fragmented patchwork of administrative delays, denials, and frustrations. The sicker you are, the more hurdles you and your care teams face. Our insurance partners need to do better, especially when nurses, physicians and other caregivers are reporting high levels of burnout and job dissatisfaction.”
St. Charles is not alone in expressing concerns about Medicare Advantage plans. According to the American Hospital Association, the AHA “is increasingly concerned about certain (Medicare Advantage) plan policies that restrict or delay patient access to care, which also add cost and burden to the health care system.” Additionally, Medicare Advantage plans are under investigation for fraud and delays and denials in coverage.
“We are seeing different outcomes for patients based on the type of insurance they have; with those on Medicare Advantage experiencing higher rates of denials and longer hospital stays, meanwhile our providers must jump through hoops in order to get the care their patients need approved,” said Matt Swafford, chief financial officer for St. Charles. “We recognize changing insurance options may create a temporary burden for Central Oregonians who are currently on a Medicare Advantage plan, but we ultimately believe it is the right move for patients and for our health system to be sustainable into the future to encourage patients to move away from Medicare Advantage plans as they currently exist. We want to share this notification with seniors in Central Oregon so they have enough time during open enrollment this fall to sign up for traditional Medicare.”
Next steps
St. Charles Health System is evaluating its Medicare Advantage contracts with PacificSource, Humana, HealthNet and WellCare this fall and winter.
Should St. Charles no longer be considered “in-network” with these Medicare Advantage plans, patients who are currently on these plans may need to choose another insurance plan to avoid changes in insurance coverage or payment responsibilities. Patients who may be impacted by this change will receive a letter from St. Charles in the mail in the coming weeks.
“We strongly encourage anyone currently on a Medicare Advantage plan living in Central Oregon to review their health insurance coverage during open enrollment this fall and consider making a change to traditional Medicare,” said Dr. Mark Hallett, chief clinical officer for St. Charles. “When a patient is on traditional Medicare, physicians determine a patient’s care and what is medically necessary. When a patient is on a Medicare Advantage plan, the insurer determines what is medically necessary. Medicare Advantage plans provide great benefits for people who are healthy, but we are concerned patients may not understand the barriers to care they could experience on an MA plan if they are seriously ill or require hospitalization.”
Central Oregonians who wish to explore insurance options, can contact:
- Oregon Senior Health Insurance Benefits Assistance (SHIBA) at 800-722-4134, option 2,
- 800-MEDICARE (800-633-4227),
- Council on Aging of Central Oregon at 541-678-5783,
- or an insurance broker of your choosing.
