BEND — Phones have rung steadily at medical and insurance offices after St. Charles Health System announced it may drop four Medicare Advantage programs, a decision that could come as early as this fall.

Early Tuesday morning, Aug. 15, Henrik Jahn, president of InsureBend, a Bend insurance agency, emailed his clients to explain the ramifications of the health system’s announcement. If the hospital opts to not accept patients on the four Medicare Advantage plans, many will have no choice but to cross the Cascades to find care, Jahn said.

Others could delay their hospital care or choose to go to a St. Charles hospital but pay out of pocket or pay out-of-network rates, he said.

“I’ve heard from a lot of people,” Jahn said. “Medicare Advantage is an affordable alternative and many people will not be able to afford to buy Medicare supplemental plans. It is terrible for medically sensitive people.”

Hospital considers changes

St. Charles weighs dropping Medicare Advantage

Seniors typically choose Medicare Advantage plans because they can offer low or zero monthly premiums, coverage for dental, vision, drugs, alternative care like chiropractic services, nutritional care and even gym memberships. In January, more than 30 million Americans were enrolled in some kind of Medicare Advantage plan, according to a Kaiser Family Foundation study.

The St. Charles health system, a nonprofit corporation that employs more than 4,300 people at its four hospitals and health care centers, said Monday it was looking at dropping Medicare Advantage programs from PacificSource, HealthNet, WellCare and Humana. The reason cited was a high denial rate, a heavy burden of paperwork and delays in transferring patients to different levels of care.

“We want the community to know we are evaluating our participation in these plans so anyone who might be affected can have time to prepare during the open enrollment this fall,” said Matt Swafford, St. Charles Health System chief financial officer. “We understand that these Medicare Advantage plans can be popular, and they work well, so long as you don’t actually need them.”

The health system is encouraging patients to consider traditional Medicare, rather than the Advantage plans, while it reevaluates its participation with all Medicare Advantage plans, Swafford said.

When Bend resident Pat Preston had his hip replaced there were some delays even with his dual health insurance coverage. None of the delays were onerous, said Preston, 76. Preston said he chose Medicare Advantage because of the low premium and caps on out-of-pocket expenses.

“I rarely have had to say I couldn’t get care,” Preston said. “Without this kind of plan, the financial burden will be huge. How am I going to afford the cost of drugs or being out of network?”

Dr. Wayne Nelson, a Bend vascular surgeon, said that his experience has been similarly frustrating as the ones St. Charles has experienced with denials and a mountain of paperwork for patients using Medicare Advantage plans.

“They have increased the administrative burden on our practice tremendously over the past year or so,” Nelson said. “We have found it difficult to get patients the care they need and the care we consider the standard.

“And when we get denied, we call the insurance provider and get stuck in a phone tree and never get through. Outside of an emergency setting, it’s difficult to provide care for patients.”

As a physician, Nelson sees the Medicare Advantage’s requirement for preauthorization as a way to wrest patient control from the doctor and put it in the hands of the insurer, he said.

“The procedures and services they deny are Medicare-approved things,” Nelson said. “The Medicare Advantage system is inserting this third party and interfering with what I feel is the best avenue for the patient.

“It is increasingly difficult to take care of people.”

At the Oregon Health & Science University, it too has experienced additional administrative challenges when working with some Medicare Advantage plans. But the hospital believes that many Medicare Advantage plans offer enhanced benefits in comparison to traditional Medicare coverage, said Franny White, OHSU spokeswoman.

“As the state’s academic health center, OHSU is committed to improving the health and well-being of all Oregonians,” White said. “To that end, we negotiate contracts with insurers to provide high-quality healthcare to as many patients as possible. OHSU approaches these negotiations in a collaborative way, while keeping patient access and continuity at the fore front. Our primary goal with all contract negotiations is to preserve access to the vital services that our patients rely on.”

St. Charles said it has brought up its concerns a number of times to PacificSource, which insures about 115,000 Central Oregon customers, 15,000 of whom are on a Medicare Advantage plan.

However, Jeremy Vandehey, PacificSource Oregon market president, said the company has sent several requests for meetings to St. Charles, and made offers to amend the contract to address the concerns, but nothing has been resolved.

“We sent them a detailed proposal per their request just last week,” Vandehey said. “We remain open to addressing their concern and finding out specifically what their issues are, what they need resolved and working together on a resolution.”

Swafford said that while the health system would prefer to keep negotiations private, it needed to respond to PacificSource’s statement.

“These meetings have brought about little or no meaningful and enduring change to address our ongoing and longstanding concerns related to denials and delays that adversely affect patient safety,” Swafford said. “We have yet to receive a written proposal.”

The health system has said it’s talking about this now because open enrollment runs from October through December.

“It affects a lot of people,” Vandehey said. “Navigating the health care system is not an easy task on a good day. This is a big issue for the community.”

Eliminating the hospital component can affect other providers in the community as well, he said. Insurance plans typically require a hospital within a certain geographic area.

The current contract with PacificSource runs through March 2024.

The health system’s decision to consider eliminating PacificSource also will affect some members of the community who have dual coverage with Medicaid and veterans.

Kim Bangerter, CEO of Central Oregon Independent Practice Association, which represents 500 independent clinics in Central Oregon, said including a hospital in a plan is vital to the viability of a health insurance offering.

“Medicare Advantage programs are what the future will be,” Bangerter said. “Costs are managed and consumers get a wider range of options and that all lowers the cost of care.”