Patients & Nonprofits Struggling to Navigate the Split Between Big Insurer and Major Bronx Hospital

The impasse between United Healthcare and Montefiore Hospital has put pressure on consumers and employers to figure out how to maintain access to trusted doctors amid a public-health crisis.

Nearly six months since a major New York City hospital system and a powerful insurer severed their relationship, some of the tens of thousands of affected patients are still scrambling to deal with the fallout. 

Several Bronx nonprofits are reeling from the change and state officials seem to have taken little action to push for a compromise.

United Healthcare (UHC) announced on Jan. 1 that physicians and facilities affiliated with the Montefiore hospital system were no longer part of its network after the two sides couldn’t agree on a menu of reimbursement costs. UHC claimed that Montefiore was asking for exorbitant cost increases, while Montefiore alleged that UHC was improperly using its market power to increase profits.

The impasse affected some 60,000 patients and their employers. The latter list included prominent Bronx nonprofits like Fordham Bedford Housing Corporation, Northwest Bronx Community and Clergy Coalition, University Neighborhood Housing Program, Concourse House and Part of the Solution (POTS).

A dispute over cost

Both companies are major players in their respective industries. United Healthcare is one of the largest health insurance companies in the country—by some measures, it is #1 in market capitalization and #3 in market share—with revenues of $257 billion in 2020 and just under 40 million customers worldwide. Along with Mount Sinai and New York-Presbyterian, Montefiore is considered one of the “big three” hospital chains in the New York City area, with 10 hospitals, a nursing school, a medical school and 200 other facilities spread across the Bronx, Westchester County and the Hudson Valley.

UHC blames the dispute on Montefiore, which it claims is already the most expensive hospital in the area. “Our latest proposal to Montefiore would provide a significant increase to the health system’s prior reimbursement rates, which were already the highest in all of New York City. Unfortunately, Montefiore is now demanding price hikes of 43 percent over the next five years for its hospitals and physicians, which would drive up health care costs by $434 million,” a UHC spokesperson told City Limits.

“Our most recent offer remains on the table for Montefiore to sign and we ask that they accept our proposal rather than continuing their demands for egregious price hikes that are not affordable for the New York residents and employers we serve,” the spokesperson continued.

Montefiore disputes that version of the story. The hospital says UHC ignored Montefiore’s offers to negotiate for two months last summer. Montefiore says it has asked only for single-digit, year-to-year increases in reimbursement costs, although it couldn’t share documentation to that effect.

“United won’t agree to rate increases that are lower than the ones they agreed to in 2018; a time before the pandemic, before hospitals and communities suffered the unprecedented health and economic challenges we are seeing today, and a time before United made the record profits they are seeing today,” says a Montefiore spokesperson.

“United’s claims about our rate increases are simply fiction. In reality, we have only ever asked for single digit annual increases consistent with rates paid by every other national insurer,” the spokesperson continued. “We can’t force United to change its mind, but we can help patients find a path to preserve their relationships with their doctors without United—and that’s what we’re doing.”

UHC has had similar disputes with other medical providers around the country. The insurer broke ties late last year with CaroMont Regional Medical Center in North Carolina. In January, the company ended its relationship with Envision, a hospital chain active in 45 states. The following month, the American Hospital Association asked the federal Centers for Medicare & Medicaid Services to intervene to stop UHC from changing its approach to paying for lab services. And U.S. Anesthesia Partners, a national medical practice, sued UHC last month in two states alleging that the insurer is trying to crush the practice “like a boa constrictor” by driving business toward medical practices that UHC owns through its Optum subsidiary.

Patients left scrambling

Some employers had only recently renewed their enrollment with United Healthcare when the break with Montefiore was announced. Among these were Fordham Bedford Housing Corporation, Fordham Bedford Community Services, Concourse House and the University Neighborhood Housing Program, all key players in the Bronx affordable housing and social services sectors who have been UHC customers for years.

“When we renewed our contract with UHC on September 1, 2020, we were unaware that Montefiore’s network contract was expiring on December 31, 2020. We received notification from UHC about a month before the end of the year that the contract was endangered. When the contract was not renewed, we received word from UHC in January,” the leaders of those four organizations wrote to the state Department of Health earlier this month. “In the midst of the pandemic, many people’s long-term relationships with their doctors were disrupted.”

Rosanna Viera, Fordham Bedford Housing’s director of development, was one of those people. She’s been with the organization since 1999 and has had Oxford insurance, which is offered by United Healthcare, all that time. In early January she was diagnosed with COVID-19. “I tried to call and set up just a phone consultation with my doctor and when they realized that I had United [the receptionist] said, “Oh the doctor can’t speak with you. Oh, the doctor won’t be able to consult with you,’” she says.

“I was a nervous wreck. I wanted to speak to a professional, you know?” she said. “So that was a little disappointing.”

Fortunately, her symptoms were relatively mild: a few days of severe back pain and the temporary loss of her sense of smell. Viera now has no primary care physician. Her gynecologist, fortunately, remains within her insurance network. The looming concern is what to do about her 11- and 14-year-old children, who currently see the same pediatrician Viera herself went to as a kid.

“Their physical is scheduled for July and I think that I’m just going to pay out of pocket, as crazy as that sounds,” she says. “I have a trusted pediatrician and I don’t want to take a name out of a book. I’ve had my share of primary doctors and I don’t want to put my kids through that. It takes time for kids to develop a relationship so they are comfortable.”

Organizations whose enrollment came up for renewal soon after the UHC-Montefiore split was announced have had a chance to shift plans, but that doesn’t mean it’s been easy.

“This was actually a really stressful experience,” says Sandra Lobo, the executive director of the Northwest Bronx Community Clergy Coalition. “There was a serious split with staff of folks who wanted to stay with United Healthcare and half the staff needing to change because their primary doctors were and have been at Montefiore for a really long time and would lose access to them because of this.” Her own children, who have been seeing the same doctor since infancy, would have lost access.”

In communities of color where a lack of trust in medical providers might have contributed to slow sign-ups for the COVID-19 vaccine, Lobo sees the UHC-Montefiore break as unhelpful.

“Forcing people to shift doctors that people have intentionally chosen and have developed relationships and trust with suddenly and starting over only exacerbates this inequality and mistrust, and that will have repercussions beyond people’s pockets for low-income communities of color,” she says.

State involvement slim

The housing organizations say they have contacted the governor, the attorney general and the state Departments of Health and Financial Services, but have heard nothing from most of them. The health department replied in April that it “generally does not get involved in the negotiation of Managed Care Organization/provider agreements as this is a contractural matter between the parties that is not within the department’s regulatory authority.”

The health department did not respond to City Limits’ request for comment. When asked if the Department of Financial Services, which regulates insurance companies, had made any effort to broker a compromise between UHC and Monte, a spokesperson for DFS merely referred City Limits to an information page for patients whose doctors are no longer covered.

“It’s very frustrating,” says Assemblymember Jeffrey Dinowitz, who represents the area of the West Bronx where Montefiore’s network is headquartered and where the nonprofits are located. He says he’s seen no evidence of any effort by the state to prod the parties to settle their differences. “I think they could bring pressure,” he says. “I don’t have the impression that has happened. If they got a call from the Commissioner of Health that said, ‘Settle this thing, already,’ maybe it would help.”

“To me it’s outrageous,” Dinowitz says. “You have a huge corporation and a huger corporation and on a thing like this I don’t really take sides, but I’ve got to say I’m more sympathetic to one side than the other. In this case, I think the bigger entity”—United Healthcare—“is using the fact that it’s so huge to not negotiate a settlement that people in the Bronx need.”

A battle of behemoths

The impact of the split is magnified by Montefiore’s huge presence in the Bronx: It is not easy to find a doctor, use a clinic or visit a hospital that is not affiliated with the system. Montefiore has grown considerably over the past eight years. Montefiore New Rochelle, Montefiore Mount Vernon, Schaffer Extended Care Center Montefiore School of Nursing, Montefiore Westchester Square, Nyack Hospital,

White Plains Hospital, Saint Joseph’s Medical Center, Burke Rehabilitation Hospital, St. Luke’s Cornwall Hospital and Albert Einstein College of Medicine are all facilities that the system has either launched, taken over or formally affiliated with since 2013.

This complicates Viera’s search for new doctors for herself and her kids. “I know there are options, but there aren’t too many. As you probably know, everywhere you turn, there’s Montefiore.” She plans to ask her pediatrician for a recommendation on a new provider for her kids but she suspects, “Most of the doctors she knows will be in her network.”

Dinowitz acknowledges Montefiore’s enormous presence. Referring to the properties along Bainbridge Avenue south of the hospital system’s main hub, he says, “Over many years, I’ve seen Montefiore bit by bit buy up every private house down that block and around.” But Dinowitz notes that, for better or worse, consolidation is a trend across healthcare, not just in Montefiore’s portfolio. “The Bronx and Montefiore have a very close and maybe symbiotic relationship,” he says. “The number of jobs—all kinds of jobs—they provide is very important to the Bronx. The healthcare they deliver is very important to the Bronx.”

To some of the nonprofits who’ve had to navigate the dispute, the episode only reinforces the healthcare reform that has long been on their agenda.

“This is why we have been organizing around the New York Health Act,” which would create a single-payer system in the state, “so that residents don’t have to go through this rollercoaster experience to access healthcare,” Lobo says.