ProMedica group physicians say they have not had a rate increase from Aetna in six years, an issue that has ProMedica on the cusp of terminating its contract with the giant health insurer and making coverage unavailable to about 28,000 ProMedica patients.

Aetna, the nation’s third-largest health plan, pays lower rates to ProMedica doctors than any other local or national commercial carrier, said Dr. James North, a salaried family practitioner with the ProMedica Physicians Group.

If the two sides can’t resolve their dispute, the 950-doctor ProMedica Physicians Group could cancel its contract with Aetna on Jan. 1, causing 19,000 Aetna commercial customers to lose coverage with the doctors immediately and another 9,000 Aetna Medicare Advantage customers on June 1.

Under that scenario, an Aetna-insured patient getting care from a ProMedica group doctor would be billed personally 100 percent for the services, then have to try to get reimbursement directly from Aetna.

The contract termination would not affect Aetna coverage for ProMedica hospital and ancillary care. Doctors in the ProMedica Physicians Group are salaried employees of ProMedica.

“We are just looking for parity with other payers,” Dr. North said of the Aetna negotiations in a phone interview late Wednesday.

In a statement Thursday, Aetna said talks with ProMedica are ongoing.

“We remain in active negotiations with ProMedica and hope to reach a new contract that is fair and reasonable for our members and the ProMedica System,” the company said in the statement.

Dr. North joined with ProMedica Physicians Group colleagues, Dr. Bruce Barnett and Dr. James Bingle, in penning an extraordinary public letter Sunday, without input from corporate, that detailed the issues involved in the Aetna dispute. It ran in The Blade’s Sunday edition.

Dr. North said the co-authors wanted to dispel some public perceptions that the doctors were holding out in negotiations as “a money grab” and to clarify that operating surpluses generated by not-for-profit ProMedica are reinvested in facilities, technology, and the community rather than returned to shareholders.

Toledo-based ProMedica has annual revenue of about $6 billion from its 12 hospitals, health plan, physicians group and HCR ManorCare senior care unit.

In contrast, Connecticut-based Aetna is more than 10 times larger than ProMedica with annual revenue of $63 billion and is publicly traded. The company has agreed to merge with drugstore giant CVS Health in a deal valued at $69 billion.

ProMedica stunned its Aetna-insured patients in late October by announcing the possibility that Aetna’s rift with ProMedica doctors could cause a contract termination by year-end.

Dr. North said the doctors gave early notice so patients would have that information as they entered the customary fall season for enrolling in health plans.

He said he knows he has lost Aetna-covered patients and he empathizes with them. He said it is nearly impossible for a person carrying insurance to go to a doctor or provider that won’t take that insurance given the cost of healthcare.

Moreover, many area employers, especially those with a national presence, provide workers with only Aetna coverage because Aetna is a national carrier, Dr. North said.

Those employers would be hard pressed to change carriers so quickly, he said.

That means he’ll probably lose more patients among the 19,000 Aetna commercial cardholders who normally see ProMedica doctors unless the dispute is resolved, said Dr. North, who joined the ProMedica Physicians Group in 1992.

Though Aetna’s rates have been stagnant for six years, the group has seen rising costs for technology, electronic medical records and a host of other necessities, Dr. North said.

ProMedica Physicians Group has gotten rate raises from all other payers except Aetna, he said.

“Aetna stands out as a much lower payer than the others,” he said.

Kathy Farber, a breast cancer survivor in Maumee, said Aetna-insured ProMedica patients are now stressing over their insurance coverage when they should be focusing singularly on getting better and staying better.

A professor emeritus at Bowling Green State University, Ms. Farber, 71, said her radiation oncologist is in the ProMedica Physicians Group and she intends to stay - at least until June - with Aetna’s Medicare Advantage plan offered through the State Teachers Retirement System of Ohio. She was treated for cancer beginning in 2008 and has shown no evidence of the disease since completing that treatment 18 months later.

She said both ProMedica and Aetna are big and wealthy. And she wants the dispute resolved so the 28,000 Aetna-insured patients caught in the middle can get back to healing.

“We are definitely collateral damage,” Ms. Farber said.

Nationally, the prices that physicians and other clinicians receive for services have been under pressure for years, said Paul Hughes-Cromwick, co-director of the Altarum Institute’s Center for Sustainable Health Spending in Ann Arbor, Mich.

Prices for physician and clinical services nationally rose a shade less than 1% cumulatively in the six years between October 2012 and October 2018, according to an Altarum healthcare price index.

Medicare, Medicaid and other government payers have used their leverage to ratchet down on physician prices and that pressure has carried over to commercial insurance payers, Mr. Hughes-Cromwick said.

Additionally, physicians in recent years have given up some of their earning power to hire in with larger salaried physician groups that work them fewer but more regular hours than they typically might see in independent practice, he said.

First Published December 6, 2018, 9:30 p.m.