Vanderbilt, BCBST hit Medicare Advantage impasse

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Vanderbilt University Medical Center and BlueCross BlueShield of Tennessee are at a stalemate over whether the hospital system will be covered in the 2016 Medicare Advantage network.

Both the health system and insurer have sent letters to Medicare Advantage patients in recent weeks warning that people may have to switch doctors to keep BCBST, or switch insurers to keep Vanderbilt physicians. Medicare Advantage is a health insurance program that substitutes for Medicare Parts A and B benefits for people ages 65 and older.

Letters, sent to The Tennessean by two patients, were both dated Sept. 28 and point to a disagreement over rates for the 2016 calendar year.

In the letter, Vanderbilt said it is “troubled by this decision by BlueCross to terminate our contract.”

The letter, signed by Chief Medical Officer Dr. Paul Sternberg, said the health system is “not currently negotiating or seeking any additional rate increases for next year. BlueCross required, on short notice… that VUMC accept a significant payment reduction or they would notify our patients of this termination. We cannot provide the services you expect at the reduced levels of support BlueCross has proposed.”

Roy Vaughn, vice president of corporate communications of BCBST in Chattanooga, said the insurer has offered rates within a range set by Medicare.

“There are cost pressures in the Medicare system. We’re sensitive to that. We want to be able to provide a product where we can compete and provide affordable rates,” Vaughn said. “It may be that we may not be able to reach an agreement.”

Each said it wanted to make sure members went into Medicare open enrollment, which started Oct. 15, knowing that Vanderbilt might not be in the 2016 network.

Harold Vaughn, 71, is planning to wait to enroll in a new plan until early December. He is happy with his current plan because he doesn’t have to get referrals to specialists under the BCBST’s preferred provider organization, or PPO.

Harold Vaughn estimates he goes to a doctor six times a year — to see a primary care physician and two specialists — if nothing is wrong with him.

He’s scheduled for a back surgery in November at VUMC and is apprehensive about whether that surgeon will still be in-network in 2016 if he needs follow-up care.

If the Hendersonville resident opts to keep VUMC, his choices will narrow. Some of the other insurers mentioned in Vanderbilt’s letter, including Aetna Medicare and UnitedHealthcare, don’t offer Medicare Advantage plans in Sumner County.

If he joins Cigna Healthspring, he goes into a health maintenance organization, or HMO, which requires referrals and carries a monthly premium.

“I’m being forced to either leave BCBST or Vanderbilt. That’s frustrating,” Harold Vaughn said.

 Contract negotiations between hospitals and insurers are not unusual, which VUMC points out in a website it launched for people potentially impacted by the network change.

The website lists all of its facilities around the region, as well as the resources it offers to patients.

Medicare accounted for 29.5 percent of VUMC’s gross revenue in fiscal year 2014, according to a late 2014 report.

Saint Thomas Health and TriStar Health are covered by BCBST’s plan for 2016.

VUMC and BCBST plan to send more communications to patients before the end of the year.