Tens of thousands of SSM Health patients in the St. Louis area could lose access to in-network health providers if the Creve Coeur-based health system and UnitedHealthcare don't reach a deal.
Time is running out for the two health companies. Their existing agreement expires at the end of the year, on Dec. 31. SSM Health representatives estimate failure to reach an agreement could affect about 100,000 patients in the area.
Health systems and insurance companies regularly negotiate how much insurers reimburse hospitals for surgeries, checkups, screenings and hundreds of other procedures. Health insurers can use their massive networks of patients as leverage, while large health systems can similarly use their big size as a bargaining chip.
But UHC and SSM are in a stalemate right now, and both sides are blaming each other.
SSM officials argue the costs to provide medical care have gone up. Chief Clinical Officer Bob Pendleton, in a video posted on the health system's website and social media platforms, said UHC is tallying billions in profits while denying medically necessary care to its members.
"We cannot agree to terms that fail to support the level of care you deserve," he said. "Putting profits ahead of patients is simply unacceptable."
Pendleton also referenced coverage in the New York Times of accusations the insurer denies coverage for medically necessary treatment.
UHC representatives claim SSM officials are asking for a double-digit price increase in commercial plans over the next two years. Those costs would be passed on to employers that offer UHC coverage through benefits packages, the insurer said.
"The majority of these cost increases would come out of the budgets of local employers, impacting the money they have to grow their business and compensate their employees," a UHC representative said in an emailed statement. "We need the health system to provide a proposal that's affordable for Missouri and Illinois families as well as local companies."
The representative called SSM's allegations about how the company processes claims false and a distraction tactic and argued that care at SSM is more expensive than other providers in the region.
SSM operates 23 hospitals and hundreds of physician offices in Illinois, Missouri, Oklahoma and Wisconsin.
If the two don't agree on a contract, the loss of in-network coverage would affect commercial customers who receive insurance through employers and through United Medicaid plans. Medicare patients would remain in network, according to UHC.
Meanwhile, patients such as David Wise and his family, who live in south St. Louis County, are left in a lurch. Wise's family is insured with UHC through his wife's employer. Earlier this month, the family received a letter from SSM dated Nov. 14 that warned them their providers may soon be out-of-network.
"This is just extra stress, and my wife and I, we don't make a lot of money, so to pay out-of-network benefits just isn't possible for us," he said. "If there isn't an agreement reached, we will have to switch our care elsewhere."
Wise said it's particularly stressful since his older son has chronic health conditions that require him to regularly visit a specialist at SSM Health Cardinal Glennon hospital in St. Louis.
"Just a lot of work goes into his care, and thinking about trying to switch to a different health system in a few weeks, especially with Christmas coming up … it can take a long time to get in. It just made me really stressed out," he said. "It felt like I had to scramble to figure something out."
The SSM letter encouraged patients to call UHC or their company's human resources department to "express their frustration." Wise said the family called the number but that "it wasn't the correct number."
Although the terms of network contract agreements are usually kept confidential, health insurers and providers sometimes take grievances public when negotiations become contentious.
That's what happened when Mercy, one of the largest health systems in Missouri, last year threatened to drop out of Anthem's insurance network. The two eventually agreed to a contract, which kept hundreds of thousands of patients in-network.
Wise said he wants executives at the two companies to put themselves in patients' shoes.
"I wish the people involved in the negotiations would come down to a pediatric hospital that's affected by this and talk to the families, see some of the kids, and then go back and negotiate," Wise said. "Think about what's best for the patients, and not just the bottom line."
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