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‘Hopeless and helpless,’ patients caught between Anthem and CommonSpirit

As major insurer and hospital system negotiate, patients feel ‘used’
Ollie Hunter, 11, sits with his father Mark, brother Max, 14, and his mother Christie on Friday at their home near Durango. Ollie has myasthenia gravis, an exceedingly rare autoimmune neuromuscular disease and relies on Mercy Hospital services. But he may loose in-network access to the hospital if the insurance giant Anthem and hospital system CommonSpirit Health are unable to agree on a contract. (Jerry McBride/Durango Herald)

Ollie Hunter enjoys the same activities that any 11-year-old boy in Durango might: He likes to ski, he likes to play soccer and he’s lobbying his parents for an electric dirt bike.

He lives with his parents, Christie and Mark, and older brother Max, 14, on an idyllic piece of property on Junction Creek Road (County Road 204), just northwest of city limits. The family left the San Francisco Bay Area for Durango four years ago.

“I can ski 30 minutes away,” he says. “Anywhere else? I can’t really do that.”

But the family’s future in Durango is looking uncertain at this moment for one reason: they are insured through the Anthem Blue Cross Blue Shield Colorado network, which might consider Mercy Hospital to be “out-of-network” beginning today.

As of Tuesday afternoon, the insurance giant Anthem and CommonSpirit Health, Mercy’s owner, had been unable to agree on a contract setting a rate of reimbursement for care. The current contract expires today, meaning thousands of patients across the Four Corners will have to choose between traveling to an in-network hospital or paying bills for out-of-network care.

Ollie is one such patient. And he needs access to Mercy.

“We wouldn’t really be able to live here if we couldn’t get to the hospital,” he said.

Ollie has myasthenia gravis, an exceedingly rare autoimmune neuromuscular disease, as well as a secondary unspecified autoimmune disease. He’s a cheery, confident kid – “he’s more optimistic than I am,” his pediatrician gushed. Mark works in information technology sales and Christie runs health care management for Ollie.

His illness renders him unable to walk at times, or confined to a liquid-diet at others. Ollie has spent just two days at school since the New Year.

“We wouldn’t really be able to live here if we couldn’t get to the hospital,” said Ollie Hunter. (Jerry McBride/Durango Herald)

And, he goes to Mercy Hospital about once per week, where his primary physician, Dr. Jessica Marsh, contracts as a hospitalist. She coordinates his infusions and the care he needs with specialists spread from Denver to San Francisco.

The conflict has left the family caught, feeling like a helpless pawn, between the country’s second-largest health insurance company and third-largest hospital system.

“Why is this allowed?” Christie said. “We’re between a rock and a hard place. We can’t go out and change our insurance. There’s nothing we can do.”

A common dispute

Disputes between insurance companies and hospital systems have an inevitable aura to them.

For-profit health insurance companies have a notorious reputation for wringing every possible dollar out of the industry. And hospital systems, both nonprofit (such as CommonSpirit) and for-profit have earned a similar reputation predicated upon predatory billing tactics that rely on opacity and obfuscation.

When insurers and hospital systems go to the mat in confidential negotiations, the patients become the fodder.

Mercy Hospital in Durango is one of more than a dozen CommonSpirit facilities across the state where Anthem members will not be able to receive in-network care if an agreement is not reached between the hospital network and insurance provider. (Jerry McBride/Durango Herald)

In Colorado, there are about 35,000 Anthem members who use CommonSpirit facilities, a spokeswoman for the insurer said. Those patients, at least 4,700 of whom live in the Four Corners, will have to find new doctors who are in the Anthem network if a deal is not made. Most employees with the federal government and Fort Lewis College have employer-sponsored Anthem health insurance.

In an interview Tuesday with The Durango Herald, CommonSpirit Regional Chief Medical Officer Dr. Oswaldo Grenardo said he was “very hopeful that something will get done,” but added “my worry is that it potentially won’t.”

An Anthem spokeswoman did not address direct questions regarding continuity of care.

“On March 16, Anthem notified all health plans in the Blue Cross Blue Shield Association that CommonSpirit may be leaving Anthem’s Colorado care provider network,” an Anthem spokeswoman said in an email Tuesday. “Additionally, Anthem has communicated with our members via letter regarding these negotiations.”

Christie Hunter said she has received no communication from the insurer.

Anthem and CommonSpirit began parallel public relations campaigns earlier this year, as both organizations make the case that they are centering the needs of the patient, while the other is prioritizing profit over people.

CommonSpirit has said Anthem wants to reduce the rate at which it reimburses hospitals for care, a claim that an Anthem regional vice president has said is false. Anthem has repeatedly accused CommonSpirit of demanding an increase in reimbursement rates that outpace inflation by a factor of three.

“We are asking for a fair and reasonable rate,” Grenardo said. “… That inflated number certainly is not anywhere close to what we would consider a fair and reasonable rate.”

The dispute is not a novel predicament for either organization.

Earlier this year, over 8 million Anthem members in California were on the verge of losing in-network coverage of their doctors at University of California Health system when negotiations came down to the wire.

Dignity Health, a part of CommonSpirit, and Anthem Blue Cross and Blue Shield of Arizona failed to reach a contract by the deadline in February, leaving patients scrambling for nearly two months before the two reached an agreement.

In 2017, a contract dispute between Anthem and CommonSpirit’s corporate predecessor, Centura Health, came down to the last minute before the two parties signed a contract.

If a deal was unable to be reached by today’s deadline, CommonSpirit hospitals are likely to hold onto claims with the assumption that a deal will be reached in the near future, and those claims can be submitted after the fact.

But nothing is certain – and that leaves patients suspended between two diverging behemoth entities.

As insurers and hospitals argue, patients suffer

Two weeks ago, Ollie went to school for the first time in 2024.

“It was, like, the first day that I could take a deep breath for a second,” Christie said.

And then she came home and started going through unopened mail. The second letter was from CommonSpirit, informing her that Mercy was about to leave Anthem’s network.

Tears came next.

Christie went from “ecstatic” about Ollie being at school, to feeling “hopeless and helpless.”

The ramifications of losing in-network coverage to the area’s largest hospital for the Hunters and thousands of other patients would be immense. But even the stress of feeling “used,” as Christie Hunter put it, is enough to demand change.

“If we’re living in a mountain community dependent upon one health care facility, and this can happen with Blue Cross Blue Shield, it can happen with all of the other insurance companies,” she said.

It’s like living in town with a single bridge over the river to get out – “it makes me a little bit nervous,” her husband, Mark, said.

“This will hit my family hard,” a Durango resident said earlier this month, after he received a letter Anthem sent to members in the Federal Employee program with information on the conflict.

In some cases, patients can find alternative care at private practices, at other area hospitals or they can request continued in-network coverage in accordance with the state’s network adequacy regulations. The latter option, Christie discovered, has demanded hours of her time.

But in rural Southwest Colorado, some patients will have no other option.

Dr. Sarah Goodpastor has been preparing patients for the potential that a deal would not be reached. She works at Mercy and is one of just 22 physicians nationwide board certified in Diabetology, making her the regional expert for patients with diabetes diagnoses.

“I’ve promised that we'll stay in communication and if the out-of-pocket costs are too much, I’ll be here for them ... but that if they came for a visit they may see higher charges,” she said. “That’s obviously extremely distressing to somebody who’s got a brand-new, life-threatening diagnosis.”

The result of both negotiations, as well as the constant haggling over what insurance will cover, is substandard care, Dr. Goodpastor said. As the only place where diabetes patients can find experts in the disease and the technology used to treat it – continuous glucose monitoring and automated insulin delivery systems – losing access to the CommonSpirit facility would result in a dramatic decrease in the quality of care that Anthem patients receive.

The battles are exhausting, said Ollie’s pediatrician, Dr. Marsh.

“It makes our job so much harder because we spend so much time trying to get approval, or go jumping through hoops to get them (insurers) to cover what we’re asking,” she said through tears. “But we also see the impact that has on our patients, and it’s so frustrating.”

Marsh is a part-owner of Pediatric Partners of the Southwest. But the practice contracts pediatric hospitalist services to Mercy, so she has cared for Ollie during admissions and arranged care there with providers who are familiar with his exceedingly rare case.

“I can’t imagine a kid like Ollie showing up to another smaller hospital who don’t know him,” she said. “I think that would be really overwhelming to them.”

About one in 1 million children are diagnosed with myasthenia gravis each year. And Ollie’s case is particularly vexing, Marsh said. As a result, he gets much more thorough care with providers he knows. Every time the family sees a new doctor, Ollie must do fresh blood work.

“It’s invasive, it’s very tough on Ollie,” Mark said.

If Mercy leaves the Anthem network, the Hunters say they don’t know what they will do.

Even if an agreement comes months after the deadline, Christie said the family will have to contemplate moving, or renting a temporary place in Denver or San Francisco in the interim.

The family already spends thousands each year on travel to see specialists and out-of-pocket health care hosts. But out-of-network care at Mercy could cost them tens of thousands of dollars.

Christie is passionate about change – she doesn’t blame CommonSpirit or Anthem specifically. Instead, she wants to rally patients who also feel used for contractual negotiation purposes.

“We shouldn’t be afraid of thinking bigger,” she said.

She sees Durango as a prime example of a major problem in American health care.

“This situation needs to be resolved, obviously,” she said, “but on top of that, the situation shouldn’t occur.”

rschafir@durangoherald.com

An earlier version of this story erred in saying an Anthem spokeswoman did not respond to questions about negotiations with CommonSpirit. The spokeswoman provided a statement about the negotiations but did not address direct questions regarding continuity of care. The error was made in editing.



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