A Pennsylvania provider group has filed suit against Aetna this week, alleging the insurer conducted multiple breaches of contract.
Bridges Health Partners, which was founded by three nonprofit health systems in the Pittsburgh metropolitan area, claims in the suit that the two had entered into a value-based arrangement in which Bridges providers would share in the savings generated by improving quality and lowering costs and Aetna would make additional payments based on meeting certain quality metrics, per its 2023 contract.
However, the provider alleges that Aetna also loaded in the cost of supplemental Medicare benefits such as gym memberships, gift cards and over-the-counter stipends. Bridges said it did not agree to these terms.
Robert Zimmerman, M.D., Bridges Health Partners president and chief medical officer, said in a press release (PDF) that while the benefits do have value to members and work as an effective marketing tool, treating them as medical expenses stiffs providers of funding they need to offer critical care.
"While the incentives are good programs, they are not critical care health programs," he said. "They are supplemental programs that potentially erodes a patient’s care at our providers. If we have to pay for the incentives, we cannot provide cost-saving, patient-centered care."
"It’s egregious manipulation but also a breach of our contract with Aetna," Zimmerman said.
The group said it does not have a desire to take supplemental benefits away from patients who do enjoy and use them actively but want to ensure Aetna is providing them at its own expense. Bridges said it is losing "millions of dollars" in shared savings.
Aetna declined to comment on the lawsuit when reached by Fierce Healthcare.
The suit was filed Tuesday in Pennyslvania state court and seeks both declaratory and injunctive relief.