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Some Medicare patients could face insurance ouster

Group Health Cooperative says it plans to drop Medicare patients who are not enrolled in a supplemental plan that costs an additional $20 a month.

It’s a step the Seattle-based managed care company has been considering for years as Medicare’s fee-for-service reimbursements don’t adequately fund nor fit Group Health’s integrated care model, said Dr. Tom Schaaf, medical director of the organization’s Eastern Washington operations.

In a letter sent to about 4,000 patients earlier this month – including about 1,400 in Spokane – Group Health gave an end-of-the-year deadline for Medicare patients to enroll in its Group Health Medicare Advantage Clear Care plan.

“We believe that the best way to serve all patients is through the comprehensive and coordinated care that members receive from our integrated system,” the letter reads. “Like many medical practices, we are looking at the numbers and types of Medicare patients we care for.”

Health care providers ranging from small physician clinics to large trauma hospitals have complained for years that Medicare – the federal government’s insurance program for people older than 65 – reimburses at a rate that is often below the cost of care. In Washington, including Spokane, those reimbursement rates are exceptionally low compared with other regions in the country.

Medical providers and politicians say the disparity is based on a reimbursement formula that punishes Washington for its efficiencies, including less use of the health care system than in other parts of the country.

It has led many clinics to limit the number of Medicare patients they receive.

Spokane-based Rockwood Clinic faces many of the same challenges as Group Health when it comes to treating Medicare patients, said Ken Bryan, a revenue director for the multispecialty clinic.

“Let’s put it this way: If we treated only traditional Medicare patients, our doors wouldn’t be open for long,” Bryan said.

Supplemental plans such as Group Health’s advantage program are popular and help cover extra services that may not be fully covered by Medicare.

Group Health, for example, has about 70,000 patients enrolled in its Advantage Clear Care plan, which offers added patient services such as 24-hour nurse consultations; online access to medical records; email access to providers, including doctors; and online prescription refills with home delivery.

Whether such additional services are worth $20 a month to Medicare patients is the subject of debate. Several patients who didn’t want their names used said $20 more a month – or $240 a year – is a lot for some seniors, especially those with fixed incomes facing higher costs for other goods and services including utilities, gas and groceries.

Schaaf said Group Health hopes all of its Medicare patients enroll in the advantage plan and stay with their doctors.

“We really want to take care of these people. Many of them have been our patients for 20 to 30 years,” he said.

The issue, according to Schaaf, “frankly boils down to the fact that fee-for-service Medicare does one thing and doesn’t do another. What it does is encourages utilization of services whether they’re needed or not. So the more you do, the more you get paid, and that’s one of the things driving unnecessary procedures and costs.”

At Group Health, he said, the model of care is “designed around services that bring a lot of value to patients, but fee-for-service Medicare doesn’t pay for it. On the other hand, the Medicare advantage plan really does pay us to provide the kind of comprehensive care we want to offer.”

Schaaf said administrators and doctors at Group Health discussed such changes several years ago when the advantage plan was much more expensive. But at the time, doctors worried it would put too much financial strain on their patients.

The price has since dropped – to about $20 a month – and the issue was revisited and ultimately adopted.

At Rockwood, which is part of a care network linked with Deaconess and Valley hospitals, doctors may still accept new Medicare patients – including those who are considered traditional fee-for-service patients and those enrolled in a supplemental plan, Bryan said.

It’s the same scenario at the physician clinics connected to Providence Health Care, said spokesman Joe Robb.

“Our clinics continue to accept Medicare patients,” he said. “I don’t think any changes (are) being discussed right now.”

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