Not as advertised: Older people ‘hustle’ over diminished access to health care at ‘health care centre’

0

CENTRAL ILLINOIS (WCIA) — Retired state workers enrolled in Aetna Medicare insurance plans are living in uncertainty and delaying doctor’s appointments. More than 500 former University of Illinois faculty and employees are enrolled in the state-administered plan, which no longer includes coverage from the larger health system in Champaign and a number of surrounding counties.

Carle Health terminated its contract with Aetna Medicare in January. More than six months later, patients are grappling with an insurer that has done little to replace providers who have fallen out of the network, and the medical facilities they know — which collectively employ about 700 providers — are downplaying the impact.

Meanwhile, Illinois taxpayers are footing the billion dollar bill for this and a handful of Medicare Advantage plans (but we’ll get to that later this week).

Carle Health: Champaign County’s “Primary Provider”

Carle is the “main supplier to our community,” said Claudia Lenhoff, executive director of Champaign County Health Care Consumers.

The nonprofit has been a resource for all things medical since 1977, and Lenhoff has been answering patients’ insurance questions for decades.

The split between Carle and Aetna is “extremely exhausting the options,” she said.

“It will hurt people. I mean, it’s really inconceivable to me that there is a health insurance plan offered to state employees right here in our community that doesn’t include Carle.

Aetna Medicare plans are no longer accepted at Carle facilities within 50 to 80 miles of Champaign-Urbana, including more than a dozen clinics and the Carle Foundation Hospital in Urbana.

Out-of-network facilities for Aetna Medicare patients are in blue. Network facilities, including Carle Eureka Hospital near Peoria and Carle BroMenn Medical Center in Bloomington, are highlighted in orange.

Carle’s explanation for breaking away from the senior health plan alluded to the fact that Aetna Medicare did not include access to all of its doctors.

Carle Health’s public relations manager, Brittany Simon, claimed that “Aetna’s previous contract never included access to the Carle Doctors Group” (that’s the collection of nearly 550 doctors practicing in the center -eastern Illinois). However, more than one Aetna Medicare patient who has seen doctors at Champaign County clinics for years confuses this statement. When asked to clarify, Simon said: ‘Billing implications may vary by location and vary between primary care services and specialist care services.’

Aetna declined questions about contract termination (but we’ll also get to the insurer’s role later in the week).

Carle Health Care Incorporated was tax exempt since the 1980s. Its annual report to the US Internal Revenue Service (IRS) in 2020 posted a profit shortfall ($116 million), but the nonprofit managed to pay its top doctors $1 million in salaries. CEO James Leonard won $4.7 million in 2020.

The separate nonprofit Carle Foundation Hospital reported net income of more than $180 million.

Christie Clinic patients are the most uncertain

Although Carle is a staple of hospital services in and around Champaign, most patients interviewed during this report have relied on Christie Clinic for primary care and a comprehensive list of specialists. That’s why Target 3 reporters began to be inundated with calls in March, when patients discovered that their doctors at the Christie Clinic were also no longer covered because of their affiliation with Carle’s Urbana Hospital.

Simon said Carle Health was unaware Christie’s doctors would be included in the fallout from his contract dispute.

Christie Clinic Chief Financial Officer Anni McClellan said in April that the majority of her doctors were back in the network, which appears to be true, but that’s not the whole story. Even in-network physicians no longer seem to be an accessible option for Aetna Medicare customers.

The need for answers is becoming more and more pressing for Julie Specht, retired from Rantoul. She has suffered from sleep apnea for a decade and needs a CPAP machine to keep her breathing from repeatedly stopping and starting again at night.

“They’re very expensive, so we really want to have them on our insurance,” Specht said.

“We are at the age where we need our insurance.”

Specht’s husband, Roscoe worked as a storekeeper at the University of Illinois for about 20 years. The couple rely on their Aetna insurance plan for several medical equipment they are used to getting from Carle Medical Supply.

“He needed what they call a transfer bench to get into the tub. And they just told us the insurance didn’t cover it. Then we found out later that it wasn’t because the insurance didn’t cover it, it was because we went to Carle Medical Supply.

The couples’ doctors are at the Christie Clinic. Specht said her pulmonologist appears to be back in the network, but her husband’s venous and vascular doctor is not.

The list of Christie Clinic providers available to Aetna patients has been constantly changing since March. In a statement Monday, McClellan said gastroenterology and foot and ankle surgery are the only two specialties that remain entirely off-grid.

This does not mean that all the other doctors are back in the network. The statement said that “at least one supplier” is networked for each specialty.

So where’s the disconnect with Roscoe’s venous and vascular doctor? Patients rely on the physician directory and Aetna’s customer service — the company that ultimately decides whether or not to cover the cost of those appointments — to determine network status, and Aetna does not list several of the doctors who the Christie Clinic says are available again. And in this limbo, patients are slow to schedule necessary appointments.

“They basically leave it up to us to check which doctors are in the network and who aren’t,” Specht said.

Mohammed State retiree Melody McDaniel also spent hours on the phone between Aetna and Christie Clinic.

“So what she told me as a recommendation was to call them every day until this was resolved. So I started doing that. But about the third day and hearing three stories , “temper got the better of me, and I’m like, no, I’m not going to do this,” McDaniel shared.

She began working at the university in 1976. She quickly moved into a supervisory role in the housing division, working there for 30 years before retiring from the state.

“I wouldn’t have traded it for anything,” McDaniel said amid the stress of his health care.

The final word is that her longtime Christie Clinic gynecologist remains out of the network. As for his attending physician for 12 years, “I may not have it by October 1st,” she said, adding that it was a direct message from the doctor.

The clinic last said it “believes” an agreement has been reached with Aetna to keep all primary care providers networked. But there is another obstacle that the clinic did not mention.

“If you have to go to the hospital, you have to go to Carle,” Specht said. She was the first patient to bring this to reporters at Target 3.

Here’s why it’s important: Doctors at the clinic must obtain what are called admitting privileges at one or more hospitals. The bottom line is that if you have to go to the hospital, your doctor can only coordinate your care where they have that privilege. This is why Christie’s suppliers who were only associated with Carle’s Urbana the hospital fell out of the network for Aetna Medicare patients for the first time.

Then, in April, McClellan said the clinic’s primary care was back in the network after “working on additional hospital relationships.”

But, as Specht pointed out, “they always do, they have a sign that says you have to go to Carle.”

There are two other Carle hospitals that, to this day, remain networked for Aetna Medicare patients (Carle Eureka Hospital near Peoria and Carle BroMenn Medical Center in Bloomington). The problem is that the two are more than an hour’s drive from the Spechts’ home in Rantoul and the hospital in Urbana to which they have lost access, which means that they and other countless other patients either have to visit an unknown doctor every time they need hospital care or do heavy driving.

It’s a tough call for the Specht family. Roscoe has required hospital care every two months for the past six months.

OSF’s Heart of Mary Medical Center has a fully-resourced alternate hospital in Urbana, but media relations confirmed that no Christie’s provider admits there.

“All Christie Clinic providers have resigned their privileges and membership in OSF Heart of Mary medical staff,” media relations coordinator Tim Ditman responded when asked if any Christie’s providers had admission privileges to the OSF.

Reporters also asked the clinic directly: Does the Christie Clinic prohibit any of its physicians from having OSF admitting privileges?

The question was dismissed, but staff continue to claim that the choice is up to doctors.

“It’s outrageous to me that state retirees who live here actually have to leave this area to get the comprehensive health care they need,” Lenhoff responded.

She said ‘It means hardship’, especially for a group of patients who are all elderly. “They most likely need help from family or friends.”

Russ Jacobson, a state retiree and longtime Urbana resident, has also been in ‘doctor’s limbo’, delaying a routine doctor’s appointment he was supposed to go to months ago. . Jacobson has a unique front row seat for what he says is a developing model.

“I know, from my son-in-law, who used to work, he worked his way up to head of the cardiac department (at Carle)…He said it’s very obvious that Carle and Christie are starting to grow together,” reflects Jacobson.

It all unfolds following a dispute between Christie Clinic and OSF Healthcare that dates back four years to when OSF first purchased Urbana Catholic Hospital.

At the time, Christie CEO Kenny Bilger blamed the clashes on business practices and patient care issues, telling the News-Gazette“It will not be resolved.”

Ironically, Bilger pointed to what they called OSF’s “spoke and hub” model, which involved sending patients from Champaign-Urbana to OSF specialists who were at least an hour’s drive away, rather than using the local care available at Carle.

OSF declined to comment at the time. In a statement simply attributed to OSF HealthCare, the company says, “There have been numerous attempts to partner with Christie…” and in June, Ditman responded, “OSF has no restrictions that prevent qualified providers from Christie Clinic to have privileges at the Heart of Mary. and other hospitals.

Carle Health does not limit where its suppliers or affiliated suppliers can admit, according to Simon.

Share.

About Author

Comments are closed.