Medicare Advantage has many restrictions, and patients struggle when they must switch doctors

"I want to make it clear this will be an involuntary separation."

Her tone was in jest, but her eyes were pure weariness as she sat in my office, wringing her hands and doing her best to fight back tears.

"Pain is something I can deal with. Finding an entire new team of doctors is not," she said as she shook her head.

If you had passed her in the waiting room, she would’ve struck you as a woman of pure poise — her hair neatly placed, her blouse tucked in and beige shoes matching her purse. Her appearance belied her inner strength and resilience. Sharon is in her 70s and has known pain most of her adult life. She was diagnosed with rheumatoid arthritis at a young age and has had numerous complications and flares. Her inflammatory disease isn’t just limited to her joints. It has contributed to complications including coronary heart disease and chronic lung disease. She recently gave up driving.

However, like many of my patients, the medical exam isn’t the hard part about coming to see me; it’s all the things that come with it: navigating health systems and co-pays, phone calls and parking fees, deductibles, networks and insurance coverage gaps known as “donut” holes.

And now she is being asked to navigate something entirely unexpected: Her Medicare Advantage plan will soon list my health system as "out of network." She will need to find a new primary care doctor, rheumatologist and cardiologist. She’s been with our team for more than 10 years and is now being asked to make a change.

"Do you even know where the next closest rheumatologist is?" she asked me, still shaking her head.

Sharon isn’t alone; she’s among thousands in my system who will be affected once United Health no longer contracts with my hospital. While younger patients on commercial plans might not be surprised by network changes, something that frequently comes with the territory of having private insurance in America, this is a new and unique challenge for seniors.

Traditional Medicare vs. Medicare Advantage

Traditional Medicare is accepted by 98% of physicians. It’s exceedingly popular and for generations has been the mainstay for insuring America’s seniors. With traditional Medicare there are no networks; patients can see any and all accepting physicians.

But the past decade has seen a rise in Medicare Advantage, also known as MA or Medicare Part C. It is a privately administered program that uses capitation, defined by the Centers for Medicare & Medicaid Services as "a way of paying health care providers or organizations in which they receive a predictable, upfront, set amount of money to cover the predicted cost of all or some of the health care services for a specific patient over a certain period of time." Patients enrolled in Medicare Advantage receive their benefits through intermediaries like United Health or Aetna.

Since 2007, the volume of beneficiaries enrolled in Medicare Advantage has nearly tripled and as of 2023, 51% of patients eligible for Medicare were enrolled in Medicare Advantage plans. Because these plans are administered through a private insurance company, seniors are now subject to shifts in contracting and network restrictions.

Such a disruption for a patient with numerous chronic diseases isn’t just frustrating, it's potentially life-threatening. It is well-studied that transfers of care pose risks to patients, especially those with more complex conditions. When you leave a health system and a team of physicians that has known you well for years, information will inevitably be lost, which creates space for mistakes to be made.

Now, here was Sharon, in my office, faced with the frustration of having to find a new team of doctors at a time when waiting lists are long and also confronting the prospect this might mean getting a lower standard of care.

I had no answers for her. Physicians, unfortunately, have little or no say when large health systems are engaging in contracting disputes with even larger insurance giants. This is happening to patients nationwide. In October a health system in Virginia and Ohio dropped their contract with Anthem Blue Cross Blue Shield for a time, which affected the care of tens of thousands of Medicare patients.

When I asked Sharon what her plan was, she replied, “I can’t get into my new system for at least six months. So my plan is to hope this gets resolved before an emergency arises.”

Monica Maalouf, M.D., is a primary care internist, associate professor of medicine and assistant dean of diversity, equity and inclusion at Loyola Stritch School of Medicine.

The views and opinions expressed by contributors are their own and do not necessarily reflect those of the Chicago Sun-Times or any of its affiliates.

The Sun-Times welcomes letters to the editor and op-eds. See our guidelines.