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CENTRAL ILLINOIS (WCIA) — Retired state workers enrolled in Aetna Medicare insurance plans are living in uncertainty and delaying doctors’ appointments. More than 500 former teachers and University of Illinois employees are enrolled in the state-administered plan which no longer includes coverage of the largest health system for Champaign and a number of surrounding counties.
Carle Health terminated its contract with Aetna Medicare in January. More than six months later, patients are saddled with an insurer that has done little to replace the providers that fell out of network, and the medical facilities familiar to them — which collectively employ around 700 providers — are downplaying the impact.
Meanwhile, Illinois taxpayers are footing the billion-dollar bill for this and a handful of Medicare Advantage plans (but we’ll get to that later this week).
Carle Health: Champaign County’s ‘major provider’
Carle is the “major provider of our community,” Champaign County Health Care Consumers executive director Claudia Lenhoff said.
The non-profit has been a resource for all things medical since 1977, and Lenhoff has been answering patients’ insurance questions for a couple of decades.
The break-up between Carle and Aetna “depletes options enormously,” she said.
“It’s going to leave people hurting. I mean, it’s really sort of inconceivable to me that there would be a health insurance plan offered to state employees right here in our community that is not inclusive of Carle.”
Aetna Medicare plans are no longer accepted at Carle facilities within 50-80 miles of Champaign-Urbana, including more than a dozen clinics and Carle Foundation Hospital in Urbana.
Carle’s explanation for breaking up with the senior health plan alluded to Aetna Medicare not including access to all of its physicians.
Carle Health Public Relations Manager Brittany Simon claimed “Aetna’s previous contract never included access to the Carle Physician Group” (That’s the collection of nearly 550 doctors practicing in east-central Illinois). However, more than one Aetna Medicare patients who have been seeing doctors at Champaign County clinics for years muddle that statement. When asked to clarify, Simon said, “Billing implications can vary by location and vary by primary care services and specialty care services.”
Aetna declined questions about the contract termination (but we’ll also get to the insurer’s role later in the week).
Carle Health Care Incorporated has been tax-exempt since the 1980s. Its annual report to the U.S. Internal Revenue Service (IRS) in 2020 showed a profit deficit ($116 million), but the non-profit managed to pay its top physicians million-dollar salaries. CEO James Leonard took home $4.7 million in 2020.
Separate non-profit The Carle Foundation Hospital reported a net income of more than $180 million.
Christie Clinic patients are left with the most uncertainty
Although Carle is a staple for hospital services in-and-around Champaign, most of the patients interviewed over the course of this reporting have counted on Christie Clinic for primary care and a comprehensive list of specialists. That’s why Target 3 reporters started getting inundated with calls in March, when patients found out their Christie Clinic doctors, too, were no longer covered because of their affiliation with Carle’s Urbana hospital.
Simon said Carle Health was unaware Christie doctors would be included in the fallout of its contract dispute.
Christie Clinic Chief Financial Officer Anni McClellan said in April the majority of its physicians were back in network, which appears to be true, but that’s not the whole story. Even the in-network doctors no longer appear to be an accessible option for Aetna Medicare customers.
The need for answers grows ever more urgent for Rantoul retiree Julie Specht. She has suffered from sleep apnea for a decade and is in need of a need CPAP machine to keep her breathing from repeatedly stopping and starting at night.
“They’re very expensive, so we definitely want to get it under our insurance,” Specht said.
“We’re at the age now where we need our insurance.”
Specht’s husband, Roscoe worked as a storekeeper at the University of Illinois for about 20 years. The couple relies on his Aetna insurance plan for multiple pieces of medical equipment they’re accustomed to getting at Carle Medical Supply.
“He needed what they call a transfer bench to get into the tub. And they just told us that the insurance didn’t cover it. Then we found out later, it wasn’t the because the insurance wouldn’t cover it, it was because we went to Carle Medical Supply.”
The couples’ doctors are at Christie Clinic. Specht said her pulmonologist appears to be back in-network, but her husband’s vein & vascular doctor is not.
Christie Clinic’s list of providers available to Aetna patients has been in flux since March. In a statement Monday, McClellan said gastroenterology and foot & ankle surgery are the only two specialties that remain entirely out of network.
That doesn’t mean all other doctors are back in network. The statement read, “at least one provider” is in-network for each specialty.
So, where’s the disconnect with Roscoe’s vein & vascular doctor? Patients rely on Aetna’s doctor directory and customer service — the company that ultimately decides whether to cover the cost of those appointments — to determine in-network status, and Aetna doesn’t list several of the doctors who Christie Clinic says are once again available. And in that limbo, patients are holding off on scheduling necessary appointments.
“They’re basically leaving it up to us to verify what doctors are in the network and who’s not,” Specht said.
Melody McDaniel, a state retiree in Mahomet, has also spent hours on the phone calling between Aetna and Christie Clinic.
“So what she told me as a recommendation was to call them every day until this was solved. So I started doing that. But about the third day and hearing three stories, “temper got the better of me, and I’m like, no, I’m not going to do this,” McDaniel shared.
She started working at the university in 1976. She quickly progressed to a supervisory role in the housing division, working there 30 years before retiring from the state.
“I wouldn’t have traded it for anything,” McDaniel said amidst the stress over her health care.
The latest word is that her longtime Christie Clinic gynecologist remains out of network. As for her primary care doctor of 12 years, “I may not have her by the time October 1 rolls around,” she said, adding that was a message straight from the doctor.
The clinic last reported they “believe” an arrangement was reached with Aetna to keep all primary care providers in network. But there’s another barrier the clinic failed to mention.
“If you need to go to a hospital, you need to go to Carle,” Specht said. She was the first patient to bring this to Target 3 reporters.
Here’s why that matters: Clinic doctors have to get what’s called admitting privileges at one or more hospitals. The gist is, that if you need to go to the hospital, your doctor can only coordinate your care where they have this privilege. That’s why Christie providers who only associated with Carle’s Urbana hospital first fell out of network for Aetna medicare patients.
Then, in April, McClellan said the clinic’s primary care was back in network after “working on additional hospital relationships.”
But, as Specht pointed out, “They still do, they have a sign up that says you need to go to Carle.”
There are two other Carle hospitals that, to this day, remain in-network for Aetna Medicare patients (Carle Eureka Hospital near Peoria and Carle BroMenn Medical Center in Bloomington). The problem is, both are more than an hour’s drive from the Specht’s home in Rantoul, and the hospital in Urbana they lost access to, meaning that they and countless other patients either have to see an unfamiliar doctor every time they need hospital care or make the burdensome drive.
It’s a tough call for the Specht household. Roscoe has required hospital care every couple of months in the last six.
OSF’s Heart of Mary Medical Center has an alternative, full-resourced hospital in Urbana, but media relations confirmed not a single Christie provider admits there.
“All of the Christie Clinic providers resigned their privileges and medical staff membership at OSF Heart of Mary,” media relations coordinator Tim Ditman responded when asked if any Christie providers have admitting privileges at OSF.
Reporters also asked the clinic directly: Does Christie Clinic prohibit any of its physicians from having admitting privileges at OSF?
The question was declined, but staff continue to claim that choice belongs to the doctors.
“It’s outrageous to me that state retirees who live here have to actually leave this area to go get the full health care that they need,” Lenhoff reacted.
She said “It means hardship,” particularly for a group of patients who are all seniors. “They most likely have to have help from family or friends.”
Russ Jacobson, a state retiree and longtime Urbana resident, has also been in ‘doctor limbo,’ delaying a routine doctor’s appointment he was supposed to be in for months ago. Jacobson has a unique front-row seat to what he says is a developing pattern.
“I do know, from my son-in-law, who used to work, he worked his way up to the head of the cardiac department (at Carle)…He said it’s very obvious that Carle and Christie are starting to grow together,” Jacobson mused.
It’s all unfolding in the wake of a dispute between Christie Clinic and OSF Healthcare that traces back four years when OSF first bought the catholic hospital in Urbana.
At the time, Christie CEO Kenny Bilger blamed clashes over business practices and patient care issues, telling the News-Gazette, “This will not be resolved.”
Ironically, Bilger pointed to what they referred to as OSF’s ‘spoke-and hub’ model, which meant sending some Champaign-Urbana patients to OSF specialists who were at least an hour away, rather than using local care available at Carle.
OSF declined to comment at the time. In a statement simply attributed to OSF HealthCare, the company states, “Many attempts have been made to partner with Christie…” and in June, Ditman responded, “OSF has no restrictions that prevent qualified Christie Clinic providers from having privileges at Heart of Mary and other hospitals.”
Carle Health does not limit where its providers or affiliated providers can admit, according to Simon.