By Michelle Crouch
As tensions escalate nationally over health care costs, insurers and health care providers are increasingly playing hardball in their contract negotiations, creating stress and confusion for patients.
That phenomenon was on display this past week in Charlotte, where Tryon Medical Partners – the largest independent primary care practice in the Charlotte region – told patients it would no longer accept the Humana Medicare Advantage insurance plan.
These disputes typically arise when contract negotiations fall through because insurers and providers can’t reach agreement on prices for care and other terms – and patients are often the losers.
“It is a health care battle of the titans, one where patients are caught in the middle since they may lose in-network access to their providers,” said Jonathan Oberlander, professor of health policy and management at the school of medicine at UNC Chapel Hill.
In this case it was a large medical provider – not a hospital – severing ties with an insurer, “although given its size, I suppose Tryon is a mini-titan,” Oberlander said.
In an email sent on Sept. 26 to affected patients, Tryon Medical said it would no longer accept the Humana Medicare Advantage plan as of January 1. The plan is one of two offered to state retirees eligible for Medicare.
Panicked patients immediately began contacting their doctors, calling Tryon Medical and Humana and even emailing state Treasurer Dale Folwell, whose department administers state health plans.
Special provision protects former state employees
Tryon’s announcement had state retirees worried they’d have to find new doctors or pay more for care.
But the state health retirement plan is slightly different than a regular Humana Medicare Advantage plan. On Friday, Folwell said “nothing will change” for former state employees on the plan, and they can still see their doctors at Tryon.
“I spoke with the founder of Tryon Medical today, and we have a great relationship with them,” Folwell said. “Our Humana Medicare Advantage people will continue to be covered.”
Under a provision in the state’s Humana plan, state retirees have an open network, meaning their benefits and copay are the same whether they see out-of-network or in-network doctors, Folwell said.
“This Humana contract is an example of us taking advantage of our largeness,” Folwell said.
In addition, Tryon will file with insurance for state retirees on the Humana plan, so patients won’t have to pay upfront and then get reimbursed as is sometimes the case with out-of-network providers.
By contrast, Tryon patients enrolled in Humana Medicare Advantage plans who are not retired state employees will be significantly affected, said David Rubinstein, an independent Medicare insurance broker with Carolina Insurance Partners.
If they have a Humana Medicare Advantage HMO, they won’t be able to see their doctors at Tryon at all, Rubinstein said. And if they have a Humana Medicare PPO, they will have a higher copay or cost sharing for each visit, he said.
Insurer-provider rifts becoming common
Experts say people should expect to see more of these disputes in the future.
As hospitals consolidate, it gives them greater power in a given market, allowing them to push insurers to accept higher prices.
For example, earlier this year, UnitedHealthcare members lost in-network access to WakeMed, the dominant health care provider in the Raleigh area, after negotiations fell through.
As United and WakeMed negotiated, United put the blame squarely on the hospital system, saying WakeMed’s prices were just too expensive.
“WakeMed has disrupted North Carolinians’ access to care,” United said in one statement. “WakeMed is seeking a 20% price hike in just the first year of our contract.”
The health system shot back with its own messaging, arguing that United was denying too many claims:
“Unfortunately, UnitedHealthcare is making it more difficult for providers like us to deliver exceptional care. This isn’t right,” a Sept. 6 WakeMed statement said. “We believe your need for medical care should be determined by you and your doctor, not an insurance company.” (emphasis in the original).
In 2021, another high-profile showdown between UnitedHealthcare and Providence Anesthesiology Associates led to some Charlotte patients at Novant hospitals being charged out-of-network rates for anesthesia.
Patients in the crosshairs
Where this all leaves patients is confused.
Martha Bahnson, 76, a retired teacher in Charlotte, said the news about Tryon Medical created incredible stress for her last week.
“I didn’t want to leave my doctors at Tryon, and I also didn’t want to leave my insurance, so that’s what made it hard,” she said.
When she shared her predicament on NextDoor, it clearly struck a chord; her post garnered more than 281 comments. Some were posted by patients in the same boat. Others were folks offering advice or expressing frustration with the U.S. health care system.
Tryon spokesman Tom Williams declined to say how many of its 185,000 patients are affected by the Humana change, or how many of those are enrolled in the state health plan.
He noted that the practice takes three other Medicare Advantage plans, and that it provided patients with a dedicated helpline to answer questions. On Friday, he said Tryon sent a followup email to patients clarifying that those on the state health plan could still see their doctors and would not have to pay more.
Bahnson said she wished that the information had come out sooner.
“I’m glad I’ll get to stay with them, but it could have been handled differently,” Bahnson said. “It’s a shame they couldn’t put better information out there from the beginning so we didn’t all go off the deep end.”
This story was produced as part of a partnership between North Carolina Health News and the Charlotte Ledger to produce health care reporting focused on the Charlotte metropolitan area.