UnitedHealthcare is currently in talks with two Midwestern health systems over contracts that are set to expire at the end of the year.
SSM Health is a Catholic, nonprofit health system baed in St. Louis, Missouri, that serves communities in Illinois, Missouri, Oklahoma and Wisconsin with 40,000 team members and 15,000 providers. The current negotiation concerns facilities throughout Missouri and Illinois.
This comes as the health insurer is also in ongoing negotiations with the Cincinnati-based health system TriHealth, which is the second-largest employer in the city and serves patients in 130 locations.
Why It Matters
These negotiations mainly focus on reimbursement rates between the health insurer and the health systems. The contracts they negotiate will impact patients and employers, as premiums and out-of-pocket costs may be affected.
UnitedHealthcare said its top priority in both cases is to reach an affordable agreement while maintaining continued, uninterrupted network access to the health system.
If the parties don’t reach an agreement by December 31, 2025, patients with UnitedHealthcare plans will be out-of-network in the new year.
In a statement, SSM Health said it remains committed to reaching a fair, sustainable agreement that protects patients and preserves access to trusted providers. Without such an agreement, the health system said UnitedHealthcare’s decision could lead to patients not having full access to high-quality care, higher out-of-pocket costs and fewer care options for thousands of Missouri families.
What To Know
SSM Health
The negotiations with SSM Health deal with employer-sponsored plans and Medicaid plans through UnitedHealthcare Community Plan. According to UnitedHealthcare, Medicare Advantage plans, including Dual Special Needs Plan (DSNP), Group Retiree and Medicare Supplement plans, are not impacted by these negotiations.
In a statement to Newsweek, a UnitedHealthcare spokesperson said SSM Health issued a notice to end its contract and is “making false allegations to distract from what our negotiation is really about, which is reaching an agreement that is affordable for the people and employers we serve.”
UnitedHealthcare said SSM Health is seeking a 14 percent price hike over two years for its commercial plans. The majority of these cost increases would come out of the budgets of local employers, which UnitedHealthcare said would impact the money it has to grow its business and compensate its employees.
UnitedHealthcare added that SSM Health is also significantly more expensive than the average cost of all other providers in its Medicaid network in Missouri, driving up costs for taxpayers at an unsustainable rate.
“Our top priority is to reach an agreement that maintains continued network access to SSM Health,” the spokesperson said. “However, we need the health system to provide a proposal that’s affordable for Missouri and Illinois families as well as local companies.”
SSM Health said UnitedHealthcare “continues to insist on creating obstacles that get in the way of delivering exceptional patient care and make patients’ access to care more difficult.”
“Our priority is ensuring patients have uninterrupted access to the high-quality care they trust,” SSM Health St. Louis and Illinois Regional President Jeremy Fotheringham said in a statement. “We cannot accept terms that fail to support the level of care our patients need and deserve. United Healthcare has a history of aggressive negotiations that impact patients directly. We are focused on patients getting the right care, at the right time, with the highest quality providers.”
The health system also claimed UHC’s billions of profits are derived from delaying and denying care to patients. SSM Health said the insurer declined to offer reimbursement rates and is unwilling to recognize the rising costs and increasingly complex patient needs at mission-based hospitals.
TriHealth
Meanwhile, UnitedHealthcare has also be in contract negotiations with TriHealth for a year regarding employer-sponsored plans, Medicare Advantage health plans, including Group Retiree and Dual Special Needs Plans (DSNP), and the UnitedHealthcare Medicaid plan of Ohio.
UnitedHealthcare said TriHealth’s proposed 35 percent price hike for commercial plans would drive up premiums and out-of-pocket costs, increasing costs by $94 million for consumers and employers. The insurer claims these price increases would “only exacerbate the unsustainable escalation of health care costs” for people in Southwest Ohio and are overall “not affordable.”
“When working with self-funded customers, we treat their money as if it were our own,” UnitedHealthcare said in a statement. “These employers have charged us with the responsibility of providing their employees access to quality, affordable health care. As the prices for health care continue to rise, employers have less money available to help grow their business through things like investments in new technologies or increase salaries for employees.”
UnitedHealthcare added that TriHealth’s proposal would increase the costs of several procedures, including knee surgery, hip replacement surgery, colonoscopies, C-Sections, MRIs and emergency room visits.
In a statement, TriHealth said UnitedHealthcare has not been a good partner and it is working to change this by negotiating for reimbursement that “reflects how well we take care of patients and responsibly manage the costs involved.”
TriHealth President and CEO Mark Clement told Newsweek in an interview that he understands the frustration and uncertainty these negotiations cause for patients and those who utilize UnitedHealthcare and said TriHealth remains motivated and committed to trying to finalize negotiate this agreement with United Healthcare before the end of the year.
Firstly, he said the health system is looking for relief from the “pretty onerous administrative burden” from UnitedHealthcare.
“We see a much higher rate of denials of care both prospective and retrospective,” he said. “In fact, last year, United denied roughly $40 million in claims for care that we had already provided and and we vigorously defended those against those denials. We were able to overturn a little more than $39 million of the $40 million, but that cost us literally millions of dollars to defend the care that was provided to those patients.”
Price transparency is another painpoint in these talks for TriHealth. Clement said TriHealth is being paid 20 to 30 percent below competitiors for comparable services and he is looking to be paid fairly.
“All we’re asking is that United Healthcare pay us what they’re paying others in the market, which is not unreasonable or unfair,” he said. “To not do that would continue to place TriHealth at a competitive disadvantage and that puts our organization at risk.”
What Happens Next
Both SSM Health and TriHealth are encouraging patients to contact UnitedHealthcare to express their desire to stay in-network with their desired provider and to visit their websites for more information about the impact of these negotiations.
The parties have until the end of the year to come to an agreement or else thousands of people will become out-of-network throughout the two health systems.
If no agreement is made, patients with UnitedHealthcare admitted at either health system before January 1, 2026, will stay covered at in-network rates through the end of that inpatient admission.
This includes pregnant patients and those undergoing cancer treatments who qualify under continuity of care protocols.
What People Are Saying
Bob Pendleton, MD, Chief Clinical Officer for SSM Health in St. Louis, said in a video statement: “The New York Times recently highlighted UnitedHealthcare’s ongoing denials of essential care, including treatment for stroke patients, so that UnitedHealthcare can make billions of dollars while delaying and declining care that providers like me have deemed clinically necessary for your best health outcomes. Putting profits ahead of patients is simply unacceptable.”
Mark Clement, TriHealth President and CEO, told Newsweek: “Because of the work that’s been underway at TriHealth for the past decade, to really focus on keeping patients healthier, better, managing chronic conditions, we’ve actually driven the cost of healthcare down for patients we serve within our system. Our patients are admitted less frequently because they don’t need to be admitted, we’re doing a better job of caring for them in the outpatient setting and in their home. So we actually think that having trial continue to be a part of United’s network, which the community very much wants keeps their network more affordable. If the care would, if the care were to go to other providers, the price, the cost would go up.”
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