Mass General Brigham removes Dana-Farber from its Medicare Advantage insurance network

MGB Health Plan said the change is driven by financial considerations, including limited federal reimbursements.

But the split comes amid a very public breakup of the longtime partnership between the two institutions, in which Dana-Farber provided inpatient cancer treatment to Mass General Brigham’s vast network of patients. US News and World Report ranked Dana-Farber, in partnership with MGB’s Brigham and Women’s Hospital, as the top cancer hospital in Boston and the third-best cancer hospital in the country.

Dana-Farber is instead planning to build a new cancer hospital with MGB’s rival, Beth Israel Lahey Health. Mass General Brigham, meanwhile, plans to invest $400 million in its own cancer institute as the Dana-Farber partnership ends in 2028.

But Clingan and his wife can’t help but suspect the exclusion of Dana-Farber from his insurance plan must be related to the breakup, given Dana-Farber’s prominence in oncology.

“It only makes sense in terms of this war that is going on [between MGB and Dana-Farber],” Clingan said. “I feel like I’m collateral damage. … For that matter, other cancer patients who are similarly situated, we’re all collateral damage.”

Currently, about 250 members of the MGB Medicare Advantage plan are actively going through cancer treatment, including radiation or chemotherapy, at Dana-Farber. They’re among 1,000 members who had or are slated to have appointments with Dana-Farber this year, a Dana-Farber spokesperson said.

Jennifer St. Thomas, MGB Health Plan’s senior vice president of commercial and Medicare markets, attributed the decision to the “challenging environment” in which Medicare Advantage plans contend that federal reimbursements are not keeping pace with rising care costs.

She said the choice was not related to “any discussions, agreements, or activities between” the two health systems.

An MGB spokesperson added that the organization’s health insurance unit makes decisions separately from the health care provider side for “both legal and business reasons.”

Regardless of motivation, the move will undoubtedly affect patients fighting cancer, said David E. Williams, president of Health Business Group, a Boston management consulting firm.

“Why would you do that to patients?” Williams said. “If you’re trying to be a good health plan, why would you go and say you suddenly can’t have access to the top cancer center in Boston?”

The decision “fits the pattern of MGB trying to win all the cancer business that they can,” he said.

A Dana-Farber spokesperson said this is the first time in memory that a health insurer has removed Dana-Farber from its network.

The network change begins Oct. 1, although patients can maintain in-network coverage of Dana-Farber providers for 90 days or through the end of their treatment plans, which could extend beyond the start of the year for people undergoing chemotherapy, radiation, cell therapy, or participating in a clinical trial, according to a letter sent to MGB Health Plan Medicare Advantage members.

In another letter to patients, Dana-Farber offered access to financial counselors as well as a list of alternative insurance options, including Medicare Advantage plans that include the cancer institute as an in-network provider.

“Dana-Farber’s primary concern is continuity of care for our patients,” a Dana-Farber spokesperson said in a statement.

Meanwhile, MGB Health Plan directed its members to other cancer care providers still in its Medicare Advantage network, including Mass General Brigham Cancer Institute, UMass Memorial Health, and Southcoast Health.

Unlike other health systems in the state that treat cancer, Dana-Farber holds a special designation with the Centers for Medicare and Medicaid Services, or CMS, that recognizes the cancer institute’s particularly complex patient population and the expensive, highly specialized care required to treat them.

As a result, such specially designated hospitals — of which there are only 11 nationwide — are given higher reimbursements by Medicare.

Medicare Advantage plans, which are an alternative to original Medicare coverage and are administered by private insurers, have the ability to negotiate lower rates with hospitals, although both parties would have to agree to that pay cut.

Those plans can also limit which providers are covered, an increasingly common trend known as “narrow networks.” It’s one of “a limited number of ways” the private insurers administering the plans can make money, Williams said, since they have to adhere to other strict federal requirements.

“Because some hospitals are a lot more expensive than others, if [insurers adjust their networks], then they can really make a material difference to their own costs, which they can then use for offering richer benefits or lower premiums,” Williams said.

The cohort of patients affected by MGB Health Plan’s decision is a small chunk of the entire plan’s members. Medicare Advantage represents about 5 percent of more than 400,000 people insured by MGB Health Plan.

The insurer’s MassHealth and commercial options will maintain access to Dana-Farber, MGB Health Plan said.

Dana-Farber has never been in-network for MGB’s plans that serve people who qualify for both Medicare and Medicaid.

Still, the Medicare Advantage patients are inherently at higher risk for needing cancer treatment since they must be 65 or older to qualify for the insurance.

From 2019 to 2023, people ages 65 to 74 were diagnosed with cancer at more than three times the rate of people ages 40 to 64. That rate was even higher among people aged 75 and older.

Carol and Eldon Clingan showed the letter they received about the change in coverage.Meleck Eldahshoury for The Boston Globe

Ever since the letter disclosing the change arrived at Clingan’s home in Dedham, he has been racked with anxiety, knowing he might have to leave his beloved doctor, said his wife, Carol Clingan.

Clingan was first diagnosed with prostate cancer in 1999 and relapsed in 2003. His oncologist put him on a $10,000-per-month drug, which Clingan expects to be on for the rest of his life, that keeps the cancer at bay.

Carol and Eldon Clingan, at a table in their apartment in Dedham, read a letter from Mass General Brigham Health Plan’s Medicare Advantage letting them know that the option will no longer be available to see their cancer doctors at Dana-Farber Cancer Institute effective Oct. 1. Meleck Eldahshoury for The Boston Globe

Now, Clingan said he’s left with a tough choice: Stay with MGB Health Plan, which he knows covers his expensive-but-life-sustaining medication, but lose access to a doctor he’s trusted for 23 years; or find another insurance plan that includes Dana-Farber, but take on the risk it won’t cover his treatment.

“It could bankrupt us if we can’t get coverage for the medicine,” Carol Clingan said. “Or he could stop taking the medicine. Well, guess what that would do?”

Marin Wolf can be reached at marin.wolf@globe.com.