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Medicare HMO plan drops popular doctor, leaving patients to wonder why

TAMPA — Walter Bennett had one question before signing up for a Medicare HMO plan: Was his doctor of 14 years, Fred Bearison, in its network?

Yes, came the answer from Physicians United Plan, a private company that contracts with the government to offer managed care plans to seniors and disabled people. So Bennett, 84, enrolled for 2014.

But in January, less than a month after seniors were locked into their Medicare picks for the year, the insurer informed him — and nearly 200 other patients — it was dropping Bearison's Valrico practice from its network.

"I cried," said Elnita Rayborn, 73, of Thonotosassa, who has seen Bearison for nearly 30 years. "I know this may sound silly to a lot of people, but when you get to our age, you bend over backwards trying to stay with your doctor."

Insurers are entitled to drop providers if they give consumers at least 30 days' notice, as Physicians United did. But the timing of the decision makes it unusual — and particularly frustrating for patients, who thought they were set for the year.

The case also illustrates the instability of some Medicare plans' networks as insurers try to protect their profits amid new financial challenges. Last year during open enrollment, UnitedHealthcare dropped thousands of doctors and a number of prominent hospitals, including H. Lee Moffitt Cancer Center and Research Institute, from its Medicare plan networks.

"I think we are in a period of some level of transition as the plans are adjusting to the new environment," said Alfred Chiplin, a senior policy attorney at the Center for Medicare Advocacy. "You always see network changes but not quite on the scale we've seen."

• • •

Medicare beneficiaries get their health benefits either directly from the government, or through privately run Medicare Advantage plans. Around 30 percent choose the Advantage plans, many of them HMOs, which in exchange for limiting access to certain providers offer the promise of lower out-of-pocket costs. On original Medicare, patients have access to every doctor who accepts it. But they also can face higher costs unless they have a supplement plan, which can be pricey.

Last year Medicare Advantage was the most profitable line of business for Florida health insurers, which are paid by the federal government based on enrollment. Physicians United Plan, an 8-year-old Winter Park company, had nearly 31,300 enrollees and made $4 million in net revenue last year, according to industry publication Florida Health Market Review.

Almost two years ago, Physicians United decided it would stop contracting directly with individual doctors and instead deal primarily with "management service organizations," said Shawn Holt, the insurance company's senior vice president of sales and marketing.

One such company is All Care Management Services. Based in Miami, the company says on its website that it operates a network of independent physicians in South Florida.

Insurance companies like dealing with such networks, in part, because it involves one contract instead of dozens, said health care consultant Kip Piper. The plans also use these companies to help cut costs.

Early last year, Physicians United informed Bearison's practice that it would no longer directly contract with his office. Instead, Bearison said in an interview, his office was directed to contract with All Care if it wanted to stay in Physicians United's network.

"I wanted to do what I felt was helpful for our patients," said Bearison. So he signed up.

• • •

Holt, of Physicians United, said his company and All Care decided to drop Bearison a couple of weeks into January. He said the move affected only Bearison's practice and was not considered during open enrollment.

Holt said one reason — he wouldn't offer any others — is that several members complained that Bearison's office turned them away. "It's unfortunate, with the timing," he said. "But we did have to act in the interest of all the members."

All Care's CEO, Claudio Arellano, did not return several messages seeking comment.

Bearison, a former member of the Florida Board of Medicine, said his office was told only the termination of his contract was "for business reasons."

"We just got the letter out of the clear blue sky," he said. "They did not send us one shred of paper that there were complaints against us."

• • •

Since Advantage plans were created, the government has spent more, per person, on Advantage beneficiaries than on those in original Medicare — as much as 14 percent more, Chiplin said. The Affordable Care Act is reducing payments to private plans so that they are in line with original Medicare.

Medicare plans typically start dropping and adding doctors during open enrollment season, he said. Members whose plans drop their doctor during the year have another brief window when they can switch to traditional Medicare. But they can only get into another Advantage plan during the fall open enrollment.

Physicians United assigned Bearison's patients to another Valrico doctor for the rest of this year. Patients can seek a new health plan that includes Bearison during open enrollment, but that new coverage won't take effect until Jan. 1, 2015.

Many said that's exactly what they plan to do. Bruce Zipper, 69, of Brandon said he'd see the new doctor this year. But he plans to return to Bearison.

"We felt like we were duped into signing up for this one," said Zipper.

Times researcher John Martin contributed to this report. Jodie Tillman can be reached at jtillman@tampabay.com or (813) 226-3374.

Medicare HMO plan drops popular doctor, leaving patients to wonder why 03/07/14 [Last modified: Friday, March 7, 2014 7:44pm]
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