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Bridges Health Partners, a clinically integrated network founded by several local community hospitals, filed a lawsuit Tuesday against Aetna that claimed the insurer is charging it and its hospitals incorrectly and not providing the agreed-upon money.
Bridges is owned by St. Clair Health, Washington Health System and Independence Health System. The organization, based in Warrendale, uses population health, analytics and evidence-based practices to improve health care for patients and lower costs for patients, health systems and its insurer partners. It has saved millions of dollars over the past several years with its programs. Part of the way it does that is through deals with insurers like Aetna for care coordination and chronic-disease management.
The original 2019 accountable care organization agreement with Aetna involved 17,000 Aetna Medicare Advantage members within the footprint to share in the savings if Bridges' health systems and physicians meet certain goals and save money. The original agreement involved Excela Health and Butler Health System, which merged in 2023 to become Independence Health System.
According to a story in the Business Times in 2020, Bridges and Aetna were to work together using data analytics of claims and clinical data to promote wellness among the Aetna members and provide earlier and cost-efficient care to manage chronic diseases like diabetes, heart disease and high blood pressure. Those diseases, when caught earlier, can be managed to the point where more serious health complications can be delayed or avoided.
But Bridges said in its lawsuit filed against Aetna in the Allegheny County Court of Common Pleas that not only is its agreement not saving money, but it’s costing Bridges and its health care partners money.
The three-year agreement covering Aetna members using Bridges’ hospitals and providers was set up to give Bridges incentive payments on performance metrics based on coordination and cost of care as well as clinical efficiency among Medicare Advantage members.
Bridges claims that after the 2019 agreement with Aetna, the insurer reduced the payments that were due to Bridges. The agreement was to pay Bridges $7.50 per member per month along with incentives of as much as 45% of any surplus in medical cost funds after expenses are met. The lawsuit claims that Aetna deducted $4 million in expenses from the medical costs that it shouldn’t have, including for fitness programs for members, over-the-counter medications and free meals after a hospital stay. Bridges said those were marketing programs it shouldn’t have to pay for and never agreed to have included.
“Aetna offers supplemental programs to entice members to select Aetna over other competing Medicare Advantage plans or traditional Medicare,” according to the lawsuit.
Aetna declined comment.
Bridges also alleges that Aetna withheld financial information Bridges needed to make a decision about whether to renew the agreement, according to the lawsuit. Bridges agreed to a higher share of payments for accepting higher amount of the risk but said that in 2022 Aetna’s reconciliation of the billing cut the amount Bridges could get from $2.8 million to $330,093.
“Aetna’s actions have injured and will continue to injure Bridges and are part of a course of conduct whereby it has and continues to breach the terms of its prior agreements with Bridges, and will breach the 2023 Agreement, necessitating a declaration and injunctive relief to prevent future breaches of the 2023 agreement,” Bridges’ lawsuit said.
The lawsuit is seeking a declaratory judgment, the money it said Bridges is due, along with attorney fees and expenses plus interest.