WASHINGTON — National insurance giant UnitedHealthcare
For elderly patients enrolled in the plan, the cuts mean they will have to find a new doctor or eventually switch to a new health plan that covers their current doctor.
The move, effective Sept. 1, follows similar cuts made by the insurer to its Medicare Advantage provider networks in 11 other states, including in Rhode Island and Connecticut, where the reductions drew outrage from patients, doctors, and lawmakers earlier this year.
UnitedHealthcare is the country’s largest provider of privately managed Medicare Advantage plans, and the ongoing cuts have prompted lawsuits by doctors, state investigations, and recent federal policy changes to better protect consumers. There is also pending legislation in Congress to prevent health plans from cutting physicians mid-year.
“This phenomenon is nationwide and needs to be addressed,” Senator Richard Blumenthal, a Connecticut Democrat, said in an interview. “I’m reviewing possible legislation that would prevent this kind of draconian discharge of providers from networks serving Medicare Advantage patients.”
UnitedHealthcare officials said the Massachusetts cuts, which will trim 2 to 4 percent of its 18,600 Bay State physicians, will most affect patients receiving care from doctors in the Boston metropolitan area of Middlesex and Suffolk counties. They would not specify where the cuts would occur.
The insurer said it would not be dropping any hospitals from its Massachusetts coverage, as it has done — to much controversy — in other states, including Yale-New Haven Hospital in Connecticut and Moffitt Cancer Center in Tampa.
The changes come amid a gradual reduction of reimbursements to private insurers that offer Medicare Advantage plans as a way to offset costs associated with President Obama’s health reform law.
Medicare Advantage provides coverage for 30 percent of Americans on Medicare through private insurers. Consumers often prefer the program over traditional Medicare because it is a one-stop shop for hospital and doctor coverage, and often includes prescription drugs, eyeglasses, and gym memberships.
For years the federal government has paid the private plans up to 14 percent more than traditional Medicare for identical services, a benefit to the insurance industry that cost taxpayers an extra $1,000 per beneficiary, according to the National Committee to Preserve Social Security & Medicare, a Washington-based advocacy group. The 2010 federal health law was supposed to close the gap, as well as provide new bonus payments to plans with the highest quality ratings.
UnitedHealthcare officials say they hope that streamlining the pool of doctors will not just save money but ultimately improve the quality of patient care — and thus improve its chances of receiving bonus payments under a new federal rating system.
Cost savings could translate into more affordable care for patients, the insurer said, with the potential for lower out-of-pocket costs for prescription and office visit co-pays.
“Network restructuring is the new normal. It’s not just UnitedHealthcare, but that’s the way health plans will be operating in the future,” said Dr. Sam Ho, UnitedHealthcare’s chief medical officer, in an interview. “Healthcare is going through so many significant changes that it’s no longer a matter of doctors providing services and health plans paying claims, but a focus on the quality and cost effectiveness of those services.”
The insurer notified Massachusetts doctors last week that they would no longer be included in the network and began alerting members this week, Ho said. UnitedHealthcare would not say how many of its 55,000 Massachusetts consumers will be affected. Nationwide, the network’s changes affect more than 300,000 seniors.
‘Network restructuring is the new normal.’
Consumer and senior advocates, as well as physician groups, expressed concern about the impact of the cuts on patients.
“We’re really opposed to their actions because it’s going to limit access to care,” said Dr. Richard Pieters, president of the Massachusetts Medical Society. “We think the decisions on how they are eliminating physicians may well be arbitrary and not based on quality. It’s very unsettling. Potentially, this is just another domino starting to fall.”
The medical society plans to meet with UnitedHealthcare to discuss the changes.
In total, UnitedHealthcare will have cut about 35,000 doctors across the country over the past six months, the insurer said; that represents roughly 10 percent of the insurer’s national provider network.
The insurer said consumers are barred from changing insurers until October when the next open enrollment period begins. Patients may appeal to UnitedHealthcare to continue covering their current doctors for a finite time in special medical circumstances, such as if they are undergoing chemotherapy, post-operative rehabilitation, or physical therapy.
Only about 3,000 seniors, or 1 percent of members affected by the cuts, have requested such permission, Ho said. Fewer than 50 percent of the requests have been approved as medically appropriate.
New guidance issued by the federal Centers for Medicare & Medicaid Services in April said the agency is in the midst of establishing a policy to allow members to switch plans if their doctors have been cut out of their insurer’s network mid-year without cause. The policy would not be effective until 2015.
Representative Rosa DeLauro, another Connecticut Democrat, said she plans to introduce in the coming weeks the Medicare Advantage Participant Bill of Rights Act that would prohibit Medicare Advantage plans from dropping doctors at any time during the year without cause.
In Connecticut, about 32,000 seniors were affected when UnitedHealthcare dropped 2,200 doctors from its network last fall, DeLauro said. Two doctors groups filed lawsuits against the insurer in US District Court accusing UnitedHealthcare of violating the terms of their contracts.
In addition to UnitedHealthcare, the Medicare Advantage market in Massachusetts is dominated by Tufts Health Plan and Blue Cross Blue Shield, both of which said they have no plans to trim their doctor networks.
In fact, Blue Cross Blue Shield of Massachusetts has expanded its network by 750 physicians when it added Mount Auburn Hospital and Cambridge Health Alliance in March and South Shore Physician Hospital Association in January.
“We are competing to grow our Medicare Advantage network, not make it smaller,” said Ken Arruda, executive director of Medicare markets for Blue Cross Blue Shield of Massachusetts. “We see this as an opportunity for our company.”
More coverage:email@example.com. Follow her on Twitter @GlobeTracyJan.