Patty Damon can see St. Anthony Hospital’s Lakewood campus from her house, but starting in May, she may not be able to go there any longer without digging deep into her pockets.
Damon has insurance through Anthem BlueCross BlueShield of Colorado, which is in a dispute with St. Anthony’s owner CommonSpirit Health. If the two can’t reach an agreement by May 1, CommonSpirit’s 10 Colorado hospitals will no longer be in-network for the 1.5 million people covered by Anthem health plans in this state.
When a health care facility goes out-of-network, patients can still opt to receive care there, but the facility can then bill them for the difference between its charges and whatever the patient’s insurance is willing to pay — which could be thousands of dollars, depending on the type of care received. Federal and state laws protect people who receive out-of-network care from surprise bills in an emergency, but not when they could choose a different hospital.
Damon has orthopedic surgery scheduled at St. Anthony in June, and she’s not sure if she’ll be able to get the procedure there or if she’ll need to find a new doctor and start the process of getting on the surgical calendar all over again. Either way, she’ll have to find a different provider for her physical therapy after the surgery if CommonSpirit goes out-of-network.
“This doesn’t seem to be about patient care,” Damon said. “This is about money, and the patient is secondary.”
Representatives of both Anthem and CommonSpirit said they are optimistic they can reach an agreement by the middle of next week, but didn’t release information on their negotiations. Both said the disagreement centers on rates.
If the two sides can’t reach an agreement, Colorado patients would need to rethink going for care at CommonSpirit ‘s 10 hospitals, eight urgent care centers, two surgery centers, seven home health and hospice providers, 26 radiology centers and five physician groups. St. Elizabeth Hospital in Fort Morgan would remain in-network until mid-July, because it has a separate contract.
While Denver-area patients have other options within a relatively short drive, patients in Summit County will have to drive to either Vail or Leadville if they need non-emergency hospital care. CommonSpirit also owns the sole general hospitals in Durango and Grand Junction.
Patients who are currently pregnant or undergoing treatment for a complex condition, such as cancer, could continue to go to the same place for care. They would have to submit the claim for reimbursement themselves, though, according to a letter Anthem sent to its customers.
Anthem alleged that CommonSpirit had asked for rate increases at more than twice the rate of inflation. CommonSpirit countered that Anthem had asked for significant reductions in rates. Since negotiations aren’t public, patients have no way to know which is true, or if both may be.
Rate disputes aren’t uncommon, as both insurers and hospital chains get larger and try to use their muscle to push for payments that benefit them. In 2021, UCHealth went out-of-network in Anthem’s plans sold on the individual marketplace in the Denver area, though the sides reached a deal to bring them back in at least some plans a year later.
Matt Pickett, president of Colorado commercial plans at Anthem BlueCross BlueShield, said the insurer is still talking with CommonSpirit, but also is reaching out to customers with complex conditions to talk about their options if the split happens. If Anthem paid the rates that CommonSpirit wants, insurance costs would go up significantly for customers and their employers, he said.
“The last thing we want to do is disrupt the care for those members,” Pickett said. “Affordability is the key issue.”
Anthem did recently reach an agreement with AdventHealth, the other half of the former Centura Health, Pickett said. HealthOne and UCHealth facilities also will remain in-network in Colorado, he said.
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Dr. Shauna Gulley, president of the physician enterprise at CommonSpirit’s hospitals in three states, said the system didn’t ask for payment increases that were more than double the inflation rate, and that what Anthem offered wouldn’t cover the rising costs of medications and labor.
“There is definitely a gap between reimbursement and the cost of care,” she said.
CommonSpirit is focused on reaching an agreement, because in southwest Colorado, patients will face four-hour drives for specialty care if Mercy Hospital in Durango goes out of network, Gulley said.
“It’s really about keeping doctors and patients together,” she said.
Damon is considering switching her insurance provider at the end of the year so that she can use St. Anthony again — an option she recognizes not everyone has, since most employers only have one insurance provider. Using a different hospital won’t be a severe hardship, but it will be an unnecessary hassle for the person driving her to her surgery, she said.
“The patient is now the pawn in this game,” she said.
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