A network of healthcare providers in western Pennsylvania is suing Aetna over what the providers allege is unfair treatment under the terms of a value-based contract.
- The contract took effect in 2023 and is supposed to reward the network, Bridges Health Partners, for reducing the cost of care while improving the health of people enrolled in Aetna’s Medicare Advantage plans.
- But in a lawsuit filed this week in Allegheny County Court, Bridges claims that Aetna is charging the network for additional costs outside the network’s control.
What costs: They are described as supplemental benefits that Aetna provides to people who join its Medicare Advantage plans.
- The benefits include gym memberships, gift cards and over-the-counter medications at CVS, which owns Aetna, according to the lawsuit.
- “We’re not against supplemental benefits as a whole,” said Dr. Robert Zimmerman, president and chief medical officer of Bridges, based in Warrendale, a Pittsburgh suburb.
- “What we’re having an issue with is, contractually, they should not be allowed to charge this back to us as medical costs,” Zimmerman said in an interview with biznewsPA.
- Zimmerman and John Grese, vice president of administration at Bridges, argued that the supplemental benefits help CVS but that Bridges never agreed to include them as part of the network’s costs.
- “We’re willing to take on risks that we can control,” Grese said. “But when we’re lowering medical spending and still being penalized by costs we cannot control, that’s where the wheels come off.”
- The Bridges network includes three nonprofit health systems: Independence Health System, St. Clair Health and Washington Health System.
- Washington Health has been trying to merge with Pittsburgh-based UPMC.
- A spokesperson for Connecticut-based Aetna declined to comment.
Why is this happening now: Bridges originally contracted with Aetna in 2019.
- At the end of each contract year, however, the network would dispute the final accounting, Zimmerman said, adding that the dispute resolution process is confidential.
- Bridges decided to file a lawsuit this year in hopes the court would weigh in on the matter, Zimmerman and Grese said.
- The network is seeking declaratory and injunctive relief to prevent Aetna’s alleged contract breaches.
The background: Bridges formed in 2015 to help its members take advantage of value-based care arrangements, which shift some of the financial risk of healthcare to providers. Traditional arrangements, known as fee for service, pays providers based on the volume of care.
- The Bridges network cares for about 160,000 people under value-based arrangements, including about 75,000 in Medicare and Medicare Advantage.
- The contract with Aetna covers about 23,000 people, Grese said.
