MONTPELIER, Va. β A Richmond-area grandfather living with cancer is scrambling to find new doctors after learning his entire medical team will be out-of-network with his insurance plan at the end of the year.
Richard Martin Sr. served in the Army, worked his way up to head of maintenance at the Federal Reserve Bank of Richmond, and is now the proud grandfather of seven. In 2013, a doctor diagnosed him with multiple myeloma and gave him three to five years to live.
Twelve years later, he's still thriving thanks to care provided by his doctors at VCU Health.
"They've taken great care of me," Martin said.
But at the end of the year, all of his doctors who keep him alive and well will be out-of-network with his insurance.
"I'm still here because of the care that I'm getting and the medications I am getting, so it's going to be daunting to find all the doctors that I need," Martin said.
Martin has the United Healthcare Medicare Advantage PPO plan. His former employer offers it to retirees, and he says the Federal Reserve keeps premiums low and the benefits are exceptional, so he plans to stick with it.
"A lot of people would die for this insurance," Martin said.
To understand why Martin doesn't want to leave his plan, consider this: his cancer treatment pills cost about $24,000 each month. There are 21 pills in a monthly container, but Martin's current plan only makes him pay $50 for the entire year for all of his and his wife's medications.
"I'm not going to leave that insurance plan, I would be crazy to," Martin said.
But that means he is now scrambling to find new providers. He's especially worried about leaving his cancer doctor.
"He knows me, he's been my oncologist for 12 years, so I don't know, I don't know how it's going to work out to be honest," Martin said.
Martin is not alone. VCU's decision to go out-of-network with his plan impacts 7,000 patients.
And just last week CBS 6 told you providers at Bon Secours Memorial Regional Hospital in Mechanicsville went out-of-network with Humana's Medicare Advantage plan, impacting more than 30,000 patients in the area.
'Itβs hurting the little guy': Bon Secours/Humana dispute could cause 36K to lose access to doctors
"It does seem like a new and different time in Medicare Advantage," said Timothy Layton, an Associate Professor of Economics and Public Policy at UVA.
He said Medicare Advantage insurance members "take a voucher from the federal government and use it to enroll in a private health insurance plan rather than enrolling in the traditional Medicare plan."
Layton, an economist, studies health insurance and said Medicare Advantage plans, which are used by 50% of Medicare patients, used to be huge moneymakers for insurers. But in the past year, that's changed as the government has tried to bring payments to private insurers handling Medicare Advantage patients more in line with payments to traditional Medicare patients.
"Their profits in those lines of business have really declined a lot, they've really hurt their stock prices and valuation in the past year," Layton said.
"As you see them getting squeezed, they feel a lot of pressure that the contracts they are getting with all of their hospital partners are as good as they can get, in that they don't have as much cushion as they used to," Layton said.
"I know that it is, money wise, everybody is trying to make money and stay ahead of the game, but it filters down to the people at the bottom is what happens," Martin said.
When asked about the argument that people at these companies, whether hospitals or insurance companies, are making substantial money and why they can't negotiate so patients can maintain their plans and continue to be in network with their providers, Layton called it "a great question."
Layton said insurers actually have low profit margins, and hospitals and providers have much higher profit margins, especially some specialties like neurosurgeons or cardiologists. But he said there could be consequences for paying providers less.
"If it's the case we stop paying cardiologists, neurosurgeons so much, some portion of them are going to become lawyers, they're going to go into finance and thatβs the competition. That just is the way it is," Layton said.
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