Not as advertised: Taxpayers, state workers spend millions on ‘depleted’ senior insurance plan

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CHAMPAIGN, Ill. (WCIA) — A multi-billion dollar managed care company reaps millions in Illinois taxpayer dollars to manage a state-administered health insurance plan for retired state workers.

Nearly seven months after that plan was diminished by a contract termination with the largest health system in Champaign and surrounding counties, Aetna has produced less than a handful of viable replacements to fill the primary care gap, leaving seniors in need of recommended routine and preventative health care to delay doctors appointments while they attempt to weed through a lengthy list of providers that, in many cases, are either not real or not realistic options.

The January split between Aetna Medicare and Carle Health’s eastern-central Illinois providers — that took several Christie Clinic doctors with it — affected at least several hundred patients, many of whom spent decades working for the state, including various roles at the University of Illinois.

Russ Jacobson, 71, worked at the Illinois Geological Survey for 34 years.

"Aetna, you know it’s supposed to be Medicare, but they’re sitting on top controlling all the access," he said during an interview at his Urbana home.

Aetna’s parent company, CVS Health, reported $2.3 billion in net profit in the first quarter of the year, an increase from this time in 2021. Aetna reaps around $100 million a year from Illinois taxpayers through the Health Insurance Reserve Fund on top of federal funding, all while holding the cards over whether these patients have a doctor to see.

Health insurance has two main functions, according to Champaign County Health Care Consumers Executive Director Claudia Lenhoff: Providing access to care and making that care affordable.

"The federal government considers an area medically underserved, in part, if the providers are more than ten miles away," Lenhoff, a decades-long expert in consumer-related health care questions, explained.

Aetna continues to advertise a Medicare HMO network of more than 130 primary care providers within that ten miles of patients in Champaign-Urbana. Many of those are Christie Clinic doctors, and a number of patients revealed during this months-long investigation that they no longer consider the clinic’s providers an option because they don’t facilitate hospital care in the metro area for Aetna Medicare plans.

Without Christie, and after cutting out a number of other providers who were too far away, not actually practicing primary care, or were nowhere to be found, reporters concluded that 17 of roughly 130 providers appear to be real, accessible options. Eight of the 17 were doctors, the others were physician assistants or advanced practice nurses, which apparently means Aetna added two doctors since an April report revealed an accessible six doctors out of a list of 168 at the time. The insurer did remove a vacant doctor’s office Target 3 reported formerly belonged to a retired primary care physician.

"It’s unfair to them, they’ve played by the rules, they worked for the state, they earn their retirement benefits," Lenhoff said after hearing patient complaints firsthand.

"And now, because of some contractual issues that they have no control over, their health care is being disrupted and their lives are being disrupted."

Eight doctors appear to be enough in metro Champaign to satisfy federal network adequacy requirements for Medicare Advantage plans, regulated by the U.S. Centers for Medicare & Medicaid Services, at least if you consider the 559 Aetna Medicare patients enrolled through the state to be a complete number of beneficiaries. Aetna would not reveal how many customers in total are enrolled, but at least a couple of patients outside of the state’s plan have called WCIA with concerns.

"There is just a lot of anxiety and panic, confusion," Lenhoff continued. "…In the lives of the people who are members of Aetna, who had no idea that this was coming."

The cost of that confusion is not just lost hours spent on the phone sorting through a directory riddled with inaccuracies. In the long term, it’s the collective health of the community.

Patients, like Jacobson, have put off routine, but essential appointments. Normally, he would see his primary care doctor every six months, "Because I have high blood pressure and take medicine, they want to check kidneys and liver and make sure that there’s no reactions to the medicine."

He canceled that preventative care out of fear of the cost that could come with an out-of-network check-up, and he hasn’t rescheduled it a few months later.

"The way my experience has been with them, to fit back into that timeframe might be hard, and I just haven’t done it," Jacobson explained.

He guessed the biannual appointment is now at least a year out.

"There’s no reason it has to be this way," Lenhoff concluded near the end of the interview.

"We live in an area that is the health care hub of not just Champaign County but multiple surrounding counties."

About a dozen Aetna patients interviewed throughout the course of this investigation feel like they’re "not getting the complete story" from their insurer. The direct quote comes from Melody McDaniel who worked at the University of Illinois housing division for 30 years.

"It would be nice if somebody had just come out and tell us, ‘This is the real reason why.’ Instead of just making you hang out here, trying to second guess, and we’re trying to read between the lines," she said.

Aetna didn’t respond to repeated questions about its responsibility in selling a plan with a misleading directory or about its role in the break-up with Carle.

Carle Health Public Relations Manager Brittany Simon didn’t elaborate beyond a statement repeated since March that says Aetna Medicare didn’t include access to the entire health system and they wanted to quote "align offerings throughout the region."

Simon confirmed negotiations with Aetna have stopped.

"There are no current negotiations in process with Aetna at this time," the response read.

Target 3 reporting on health insurance disputes throughout the year reveals a pattern of disagreements over the reimbursement rates insurers want to pay doctors. Neither company would address the topic when asked directly.

Reporters also filed multiple Freedom of Information Act (FOIA) requests to the U.S. Centers for Medicare & Medicaid Services to, in part, obtain a copy of the latest network adequacy reviews of Aetna’s directory of doctors. The federal agency has extended the deadline on those April requests.

"If you tell people, ‘This is who your providers are,’ then those should be your providers, or you should be able to change," Republican Senator Chapin Rose of Mahomet reacted. He, too, has heard of access issues from a "couple dozen" constituents.

"I don’t know much about healthcare, but I’m a lawyer. When you have a, you know, a contract, and you pay for your contract, you’re entitled to the benefit that was promised you. And these people are paying for their benefits, and they’re not getting them."

Champ,Feeds,News,Central

via WCIA.com https://www.wcia.com

July 20, 2022 at 10:35PM

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