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Hospitals dropping Medicare Advantage because of concerns with patient care

Many of you who have followed the challenges faced by Medicare in the last few years are familiar with the reporting of Diane Archer and her Just Care website.  Diane brings us this report on how hospital networks are refusing to admit patients who are in Medicare Advantage.  These hospitals have concerns with the quality of care the Medicare Advantage insurance companies are willing to provide.  Diane has suggested a helpful action would be to contact Senator Wyden’s office (202-224-5244), as chair of Senate Finance Committee, which oversees Medicare, as well as your representatives.  Ask them to intervene to ensure that insurers offering Medicare Advantage do not endanger access to hospital care. 


Karen Richter

Co President PSARA

Diane Archer

Just Care

August 16, 2023

St. Charles Health System, a large hospital system in central Oregon likely will not continue to participate in Medicare Advantage, reports The hospital system’s leaders are concerned about patient care in Medicare Advantage. People with Medicare who want to know they have access to the best hospitals, including access to cancer centers of excellence, should switch to traditional Medicare.

St. Charles is not alone; many hospital systems are not taking Medicare Advantage enrollees. St. Charles’ CEO says that the hospital system has considered dropping Medicare Advantage plans for some time because of mounting concerns. He reports that his hospital system is not alone. Hospital systems throughout the country are concerned about patient care in Medicare Advantage. The Mayo Clinic stopped taking Medicare Advantage enrollees at some sites last year.

In the CEO’s words: “The reality of Medicare Advantage in Central Oregon is that it just hasn’t lived up to the promise. 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.”

The American Hospital Association (AHA), the trade association for most hospitals reports that it “is 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.” To make matters worse, it appears that some Medicare Advantage plans are engaged in fraud as well as inappropriate delays and denials of care and coverage.

St. Charles hospital executives see higher rates of denials of care in Medicare Advantage and long arduous processes for getting Medicare Advantage plans to approve medically necessary care. St. Charles health system is considering whether it will renew Medicare Advantage contracts with PacificSource, Humana, HealthNet and WellCare.

The bottom line: With traditional Medicare, your treating physicians call the shots, deciding what care is medically reasonable and necessary, and Medicare covers that care, without  second-guessing and coming between you and your doctors. With Medicare Advantage, many insurance companies second guess treating physicians and deny care or delay care, endangering patient health.

The Office of the Inspector General has reported widespread and persistent inappropriate delays and denials of care and coverage in Medicare Advantage. But, the Centers for Medicare and Medicaid Services (CMS) has so far refused to identify the bad actors or sanction them appropriately, putting older adults and people with disabilities at serious risk.

Healthy patients in Medicare Advantage should be fine. But, even if you are healthy today, you could need complex care tomorrow and your insurance should cover that care. That’s why we have health insurance. In some Medicare Advantage plans, you might not get needed care in a timely manner, if at all, regardless of whether you need it.

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