8,000 patients left in lurch

One of the Triangle's largest hospital systems will end its contract with a major health insurer today, disrupting care for thousands of patients.

Aetna and the UNC Health Care System are fighting over how much the insurer will pay for services. About 8,000 Aetna members are caught in the middle.

Unless there's a last-minute settlement, the dispute will force Aetna members to switch to a non-UNC doctor or facility, or pay much higher "out-of-network" costs.

UNC Health owns Rex Healthcare in Raleigh, its flagship campus in Chapel Hill, and clinics and practices across this region.

Aetna is approving temporary exemptions for some members who are receiving ongoing treatment. And at least one large employer in the Triangle, drug maker GlaxoSmithKline, is allowing its workers to switch to another insurer.

But for many, the situation has created the hassle of finding a new physician or clinic. This week UNC Health officials contacted about 350 patients who had appointments scheduled after today. President Gary Park wrote to UNC-affiliated physicians encouraging them to help patients make other arrangements.

But Jennifer Marks is 35 weeks' pregnant with her first child, and she's angry.

Find a new doctor?

The Willow Springs woman was in Rex this week for an ultrasound and learned about the contract fight. Her obstetrician's practice delivers only at Rex, so she's worried she will have to find a new doctor and give birth at another hospital next month.

Marks has filled out several forms with Aetna requesting an exemption to continue receiving care at Rex, but was told it could be about 10 days before she gets an answer.

Delivery at Rex could cost up to $13,000, plus nursery fees and other expenses. Under her Aetna plan, it was fully covered.

"It puts a damper on what's supposed to be a joyous time," Marks said.

"We shouldn't have to worry about the expense and potentially switching doctors and hospital with only five weeks left," she added. "It's just frustrating: Am I going to get stuck with a huge bill in six months?"

As a backup plan, Marks' physician is lining up a doctor at another practice that could deliver her baby at WakeMed, she said.

"Worst case, I have to have some doctor who knows nothing about my entire health history and my pregnancy," she said. "They'll have to do a crash course."

Aetna is working on a case-by-case basis with members who want to continue receiving care at a UNC facility, said Aetna spokesman Walt Cherniak. Some will be granted exemptions, but most will eventually need to transfer elsewhere in Aetna's network, he added.

State law does provide some protection for patients in HMO plans, especially pregnant women, but the rules aren't as tough for people enrolled in other types of health coverage. The N.C. Department of Insurance reviews insurers' provider networks to make sure there is "adequate" coverage, but doesn't have much authority to force a carrier to pay for out-of-network providers.

Patients' other choices

In this case, Aetna has contracts with other local hospitals run by WakeMed and the Duke University Health System, so patients have other choices.

The insurance department can order an insurer to pay for a "medically necessary" procedure after an insurer denies coverage and a consumer appeals, said Insurance Commissioner Wayne Goodwin.

The state can't interfere in contract fights, he said, but "as we get calls from consumers, we will do anything we can within the law to help them."

Officials with UNC Health and Aetna say they regret that a financial feud is hurting patients. UNC Health wants more money from Aetna to keep up with rising costs, and says the insurer is paying other local hospitals higher fees.

"Aetna is not paying us market rates," said UNC Health spokeswoman Jennifer James. "We're happy to talk to them, but we feel very strongly we need to be paid reasonable rates."

Aetna contends that UNC Health's request is unreasonable, and that it's trying to control costs for members and employers who buy coverage. UNC Health's latest proposal called for a 16 percent increase at UNC Hospitals, a 22 percent increase at Rex and a 52 percent increase for Rex-affiliated physicians.

"This is very unfortunate and it's not the outcome we would have preferred," said Cherniak, the Aetna spokesman. "They have been unwilling to come back with a more realistic financial proposal."

Overhaul sows doubt

The truth probably lies somewhere in the middle. Both sides are financially healthy but are facing an uncertain future as the federal health overhaul reshapes the industry.

UNC Health's operating revenue rose nearly 7 percent last year to $995.9 million; its operating income increased 30 percent. On Friday, Aetna's stock jumped on Wall Street after the insurer announced it will pay shareholders a big dividend and forecast stronger-than-expected 2011 profit. Its fourth-quarter net income rose 30 percent to $215.6 million.

As in other corporate fights that go down to the wire, the two sides could forge a new agreement after the existing contract expires.

Last summer, after a three-month battle, Aetna agreed to a new deal with Novant Health, a Winston-Salem hospital chain with facilities across the state. And in 2007, UnitedHealthcare signed a new contract with WakeMed more than four months after dropping the Wake County hospital from its network.