When Kathy Jones and Carol Milsom got the news their health insurance company was dropping their cancer doctors from its network, they were left facing a wrenching decision: Find a new oncologist or find new insurance coverage.
Jones, who lives in Silver Creek, is in active treatment for lung cancer and leukemia. Milsom is receiving care for colorectal cancer.
Both say they felt caught in the middle of an ongoing contract dispute between Independent Health and CCS Oncology.
Independent Health in June began notifying nearly 600 active patients of CCS Oncology that it would remove the medical practice from its network for 2017. The decision also affected 1,400 inactive CCS patients. Five months later, the insurance company and the oncology practice remain in a standoff.
“My choice was to either stick with Independent Health or get a new oncologist, and I didn’t want to go with an oncologist,” Jones said. She wanted to stay with Dr. Raman Sood, who practices with CCS Oncology in Dunkirk, because the next-closest oncologists are far away in Erie, Pa., or Hamburg. “I’ve been with Dr. Sood for 14 years. So he’s my main guy. I love him.”
Jones is switching her Medicare Advantage plan from Independent Health to UnitedHealthcare.
Milsom took the other route. While she felt very comfortable receiving care from Dr. Michael Krabak, she liked the coverage she received from the insurer. So she switched to an oncologist from Buffalo Medical Group, which this month has added former CCS patients at the rate of 30 per week.
Their stories highlight the tough choices patients face as they navigate a medical care landscape reshaped by efforts to confront rising health care costs.
Dispute part of industrywide battle
CCS Oncology continues to insist Independent Health acted unfairly and caused significant harm to its physicians and patients, by removing the practice from its network. CCS Oncology has lost five oncologists since the summer, and is losing new as well as existing patients, a top administrator said.
The practice is running anti-Independent Health ads that highlight this decision.
“We need to reach out to patients and educate them,” Yi said. “We need to engage in a PR campaign clearly stating our version of the story, so to speak. We feel we were wrongfully terminated from the network from Independent Health based on the flawed cost analysis.”
Independent Health stands by its decision not to renew its contract with CCS Oncology.
The insurer said it dropped CCS because the practice refused to accept a new, value-based reimbursement method to replace the existing structure that charged a fee for each service rendered.
This is part of an industrywide battle, with Independent Health and other insurers trying to move away from reimbursing providers for each treatment session or drug used and toward a system that rewards physicians, hospitals and other providers for value and outcomes.
“Independent Health followed all regulatory and contractual requirements for the non-renewal of the physicians’ contracts and we provided substantially more advance notice than was required,” Frank Sava, a spokesman for the insurer, said in a statement.
Distance an issue
CCS Oncology patients who receive care at Sood’s Dunkirk practice say they’re in a bind.
They say if they stay with Independent Health, they would have to travel 40 minutes to Hamburg, 50 minutes to Jamestown or an hour to Erie, Pa., to find another oncologist to treat them. The patients already have to travel to Erie County if they require radiation treatment, but they can receive chemotherapy infusions in Sood’s office and see him for any consultations or follow-up visits.
“I’m the only provider for 90 miles,” Sood said. He said about one-third of his patients have Independent Health coverage.
More importantly, the patients say, this would require leaving Sood’s office for a team that doesn’t have the same familiarity with their case.
“I’ve never had a bad experience there," Jones said.
Michael Brunecz, a 79-year-old Fredonia resident who sold office furniture and equipment, was diagnosed with non-Hodgkin’s lymphoma 14 years ago. It was in remission until earlier this year. Brunecz underwent chemotherapy first, followed by 25 sessions of radiation.
He also doesn’t want to travel to Buffalo or Jamestown in the winter months.
Brunecz said he plans to make his decision on his Independent Health Medicare Advantage plan after going in for a follow-up PET scan on Dec. 4.
“I feel like I’m pulled between the two,” said Brunecz. “We’ve got enough as patients to deal with.”
Patients leaving CCS
CCS patients who receive care at one of the practice’s locations in Erie and Niagara counties have more options – and more of them are choosing to leave for another provider.
Milsom, 66, said she was annoyed to find out from a friend and an article in The News about the Independent Health decision to drop CCS.
She has had a Medicare Advantage plan through the insurer for the past year and a half, and she said she likes how the company has handled her medical and pharmacy claims.
So that’s why she made the difficult decision to leave CCS and Krabak, her oncologist. She got a list of specialists from Independent Health, and a recommendation from the surgeon who originally treated her. Milsom sought Krabak’s opinion, and he concurred.
“It was uncomfortable for me, but he knew I wasn’t doing it because I was unhappy with him,” Milsom said. “So he was very gracious.”
Amherst resident Rae Dzialak, who is 70, is dealing with a recurrence of the breast cancer she was first diagnosed with at 48.
She is a CCS Oncology patient with Independent Health coverage who decided to switch to Buffalo Medical Group in part because a doctor from the group, now retired, was her original oncologist. She also appreciated the assistance she received from Independent Health, which assigned her a case worker.
“They didn’t leave me out in the cold,” Dzialak said.
For patients who receive coverage through Medicare Advantage, there is a Dec. 7 deadline to enroll. If patients happened to be enrolled in one of the three Medicare Advantage plans that Independent Health is canceling at the end of this year, they have until Dec. 31 to enroll in a new plan.
Of course, not everyone has this flexibility. Many patients receive coverage through an employer and must stay with Independent Health. Those patients, if they want to keep their CCS oncologist, would have to pay the higher, out-of-network price for their treatment.
Rival practices gain
CCS’ competitors said over the summer they had more than enough capacity to take on any patients who wanted to leave the practice.
Since then, a Buffalo Medical Group spokesman said the flow of CCS patients switching over to the group has grown to an average of six a day, or 30 per week, over the past few weeks.
Buffalo Medical Group employs six oncologists, including Dr. David R. Dougherty, who said he begins each first session with a former CCS patient by apologizing for the circumstances under which the patient joined the group.
“People make an investment with their doctors,” Dougherty said. “We spend a great deal of time with each of them. We review all of their records, their treatment histories. We make them part of our family.”
Dr. K. Kent Chevli, president of Cancer Care of Western New York and Western New York Urology Associates, said the practices, primarily Cancer Care, have brought in “many” former CCS patients.
He declined, however, to provide a number. And Roswell Park Cancer Institute said it was impossible to say how many CCS patients have joined its community-based practices.
CCS cites harm
CCS Oncology continues to insist Independent Health didn’t give the practice a fair chance to negotiate a contract.
Yi said Independent Health has never shown practice officials the data upon which the insurer based its claims that CCS’ oncologists charge more than those at other practices. He said CCS oncologists adhere to industry standards.
The practice has not calculated how many of the 2,000 active and inactive Independent Health patients have left, but Yi said new referrals to the practice are down 20 percent to 30 percent from the same period one year ago, a development he attributes to the Independent Health decision.
“This is why this is so upsetting,” Yi said.
And he said the practice has lost five of its 22 oncologists since the summer. The departing cancer doctors all didn’t give a specific reason, but the Independent Health dispute likely was a factor, Yi said.
CCS had the right to appeal Independent Health’s decision, at least when it came to Medicare Advantage patients, but the panel of physicians who heard that appeal rejected it.
Independent Health pointed out the physicians who heard the appeal are not its employees, but Yi called some members “clearly biased” because they belong to rival practices.
Yi said he still holds out hope that the dispute can be resolved, but he said follow-up talks in October went nowhere.
“We’re willing to compromise, and they said, ‘No, it’s too late,’” Yi said.
Insurer defends action
Independent Health, for its part, has said it took this step only after the practice refused to negotiate in good faith a change in reimbursement models. The insurer previously said other practices have switched from a fee-for-service to a value-based payment model.
The insurer said in a statement that it shared ample data with CCS Oncology.
And the insurer said it works closely with CCS patients to help them find care at other oncology practices, providing six-months’ notice of the non-renewal instead of the standard 90-days’ notice.
“Independent Health has had a team in place to assist our members since June and has consistently been addressing members’ questions about their coverage,” Sava, the spokesman, said in the statement.