The Nugget Newspaper - News and Opinion from Sisters, Oregon

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, the regional health care provider said in a notice to its patients and caregivers in August.

However, the news is now coming as a surprise to many.

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, explained 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,” Gordon said. “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,” Gordon said in a prepared statement.

Some readers of The Nugget have expressed alarm in hearing the news, worried that they will lose access to the region’s only hospitals.

St. Charles is not alone in expressing worries about Medicare Advantage plans. According to the American Hospital Association (AHA) they are “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.”

“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,” Matt Swafford, chief financial officer for St. Charles, said in a news release in August.

“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,” Swafford continued.

Fall is the time when seniors everywhere are asked to review and renew their Medicare coverage and some are now scrambling in light of the October announcement by St. Charles that they have declined to continue as an in-network provider for Medicare Advantage Plans from Humana, HealthNet, and WellCare for reasons cited above.

Beginning in January, the health system will accept only Medicare Advantage plans from PacificSource, Providence, Moda, and Regence Blue Cross Blue Shield. According to additional information provided by St. Charles, only those insured by Humana, HealthNet, and WellCare who are undergoing active treatment plans for cancer care, outpatient rehab, wound care, and dialysis care can continue to receive services from the health system.

Currently, an estimated 6,000 seniors in Central Oregon belong to those plans, meaning they need to switch in order to avoid increased costs at St. Charles providers.

Navigating this event can be tricky. It falls under the disenrollment provisions of Medicare, embedded in 116 pages of complex reading. If your health plan terminates at the end of the year, you get a special enrollment period that continues for the first 60 days of the new year. This would fall under the category of involuntary disenrollment.

Talk with your carrier — Humana, HealthNet, and WellCare in this case — and discuss your rights. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you are hearing or speech impaired, call 1-877-486-2048. Citing patient confidentiality, Humana representatives would not speak with The Nugget when we sought clarification.

In 2023, 30.8 million people are enrolled in a Medicare Advantage plan, accounting for 51 percent of the eligible Medicare population and $454 billion (or 54 percent) of total federal Medicare spending (net of premiums). The average Medicare beneficiary in 2023 has access to 43 Medicare Advantage plans, the largest number of options ever.

Oregon Senator Ron Wyden, issued a blistering two-page statement last month before the Senate Committee on Finance, of which he chairs.

Included in his statement: “There is a long history of rip-off artists in the private sector trying to take advantage of seniors who depend on their flagship health program, Medicare. Since I served as the director of the Oregon Grey Panthers, something like a year or two ago, these unethical salespeople would often sell seniors 10 to 15 separate, unnecessary Medigap policies that weren’t worth the paper they were written on.”