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‘Very angry’ patients await resolution of Mercy, Anthem dispute

Contract between hospital system and major insurer lapsed May 1
Mercy Hospital in Durango is one of 11 CommonSpirit Hospitals statewide that are considered “out-of-network” by Anthem Blue Cross Blue Shield of Colorado. About 5,000 patients in the Durango area are impacted by the expiration of a contract between CommonSpirit and Anthem. (Jerry McBride/Durango Herald file)
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Two weeks have passed since the contract expired between Anthem Blue Cross Blue Shield of Colorado and CommonSpirit Health, leaving tens of thousands of patients without in-network access to their doctors.

“I’m sick about it,” said Julie West, a Durango resident with a chronic autoimmune disease that demands at least quarterly visits to CommonSpirit’s Mercy Hospital.

West sees a slate of specialists at Mercy, including a nephrologist whose services are not available elsewhere in the region.

“Where do I go, because I have Anthem?” West said.

Throughout Southwest Colorado, Anthem members like West are distraught, angry and confused.

The contract dispute came to a head on April 30, when Anthem and CommonSpirit failed to negotiate a reimbursement agreement and the previous contract expired. Statewide, 35,000 people were left without in-network access to their health care providers.

With 11 CommonSpirit hospitals and dozens of other care facilities considered out of Anthem’s coverage network, Blue Cross Blue Shield members must choose one of three options: pay the higher out-of-network rate for care, switch doctors, or try to negotiate continued in-network rates under the continuity of care policy or the state’s network adequacy regulations.

Anthem members with “serious medical conditions” were previously informed that in-network care would be covered at CommonSpirit facilities automatically through July 30.

Employees at major institutions in the region, including La Plata County, Fort Lewis College and federal public land agencies are part of employer-sponsored Anthem health care plans – and now have no in-network access to the region’s only full-service hospital. Between the county and the college alone, more than 1,800 employees and family members have lost access.

Spokeswomen for CommonSpirit and Anthem say the negotiations remain active, and both organizations are committed to reaching a resolution.

A transitional care nurse works at Mercy Hospital in 2021. Thousands of patients are pondering whether to switch providers or try to wait out contract negotiations between Anthem and CommonSpirit. (Jerry McBride/Durango Herald file)
Making sense of reimbursement rates

Anthem and CommonSpirit have launched volleys of public relations attacks at one another, as each seeks to cast the other as the bad guy.

The contract in question sets the rates at which CommonSpirit hospitals and providers are reimbursed by Anthem for care.

Anthem has argued that CommonSpirit’s rates are far too high, and that those costs will land on the backs of patients in the form of premium hikes.

“This negotiation is about healthcare affordability,” Anthem spokeswoman Emily Snooks said in an email. “CommonSpirit continues to demand unacceptable price increases for Colorado consumers and employers.”

In 2021, the national CEOs of Anthem and CommonSpirit made $19.3 million and $35.4 million, respectively.

CommonSpirit has invoked its nonprofit status and argued that it reinvests profits back into its hospitals.

In previous interviews, CommonSpirit executives have said the reimbursement rates Anthem is offering do not cover the actual cost of the care.

The question of reimbursement rates largely relies on Medicare, the taxpayer-funded government health care for senior citizens, to provide a comparison. Some consumer advocates have argued that CommonSpirit demands reimbursement rates from private insurers that significantly exceed Medicare rates.

On the other hand, hospital systems and their advocates say Medicare reimbursement rates are so low that payment from private insurers must balance out the losses hospitals sustain when treating Medicare patients.

Claire Barnard, registered nurse, left, and Jennifer Hyson, director of women’s services at Mercy Hospital, work in one of the birthing rooms at the hospital in 2019. (Jerry McBride/Durango Herald file)
Patients face unpleasant options

Despite regulations ensuring patients who are already receiving care for serious ailments can extend their in-network coverage in these types of situations, Anthem members have spent hours on the phone and faxing documents to their insurer trying to secure assurances they will not be stuck with a sizable bill.

Both Anthem and CommonSpirit have indicated that patients who have secured continuity of care benefits should not be billed the full cost of their care, and that providers should submit bills to Blue Cross Blue Shield as usual.

“CommonSpirit providers should collect only in-network member cost shares from Anthem members and not balance bill the member – this is in effect through July 30, 2024,” Snooks said.

However, multiple patients report that obtaining the necessary documentation to ensure proper billing occurs has demanded hours on the phone, sometimes with no results.

Christie Hunter, whose son has a rare autoimmune disease demanding weekly trips to the hospital, said Mercy Hospital staff members informed her she would need to produce a letter from Anthem ensuring continued benefits – a letter she has not received in the two weeks since she was told that her family’s care would continue to be covered at in-network rates.

Having trouble with insurance coverage?

If people are experiencing issues with Anthem not responding or not responding in a timely manner, they can contact the Colorado Division of Insurance Consumer Services Team at (303) 894-7490, DORA_Insurance@state.co.us or at doi.colorado.gov.

DOI has also compiled a list of answers to frequently asked questions available at bit.ly/3wFxv47

“Most people are frightened that they are going to be paying enormous bills for something they have no control over,” said Emma Tomlinson, who heads up the Health Insurance Literacy Program at La Plata County Public Health.

Regulations restrict people from switching insurance providers outside the open-enrollment period, from Nov. 1 to Jan. 15 each year, save for special circumstances such as life-changing events which trigger a special enrollment period.

And although the dispute might feel like the kind of event that would qualify someone to switch to another insurance company outside of open enrollment, Anthem customers are stuck with their health plans until the end of the year.

As negotiations drag on, patients in and around Durango like Joyce Cohen are scrambling for solutions.

Cohen fell skiing in January and the spill left her with a torn ACL and a sprained MCL and LCL.

She finished a regimen of physical therapy when her hamstrings began causing her pain. Using the internet, she determined she had hamstring tendinitis.

“This is self-diagnosed on the internet because I cannot go see my doctor,” Cohen said.

What is the point of having insurance, she wonders. Cohen has yet to go through the hassle of finding a new doctor, and says she is holding out hope that her insurer, Anthem, will reach a deal with CommonSpirit.

In the meantime, she is “very angry.”

Not everyone can wait, however.

West, the patient with the autoimmune disease, could fall seriously ill without regular monitoring of her kidney function.

When her nephrologist called to tell her that an appointment scheduled for the end of May would need to be moved because of the contract negotiations, West didn’t know what to do.

“That’s not an option for me,” she said. “I have to be followed regularly.”

Farmington has the next-closest kidney specialists, but West says that after nine years with her doctor, she isn’t particularly comfortable seeing somebody else.

She filled out the continuity of care form and is waiting to hear back.

“People that are living with any sort of illness – it’s so stressful already,” West said. “So to have to worry about getting health care for that illness is really upsetting.”

Politicians’ hands tied

At the local and state levels, elected officials are expressing worry about the dispute.

“It’s causing untold financial stress, potentially, (and) certainly health care stress, for thousands of La Plata County residents,” said County Commissioner Marsha Porter-Norton during a meeting Tuesday.

In a joint news release issued two days after the contract’s expiration, State Sen. Cleave Simpson and Rep. Barbara McLachlan, the region’s representatives in the General Assembly, said the impasse puts critical care out of reach for consumers in Southwest Colorado.

“Coloradans in rural communities often have to travel hours for care, but forcing patients to drive to Colorado Springs or Grand Junction to receive treatment is not an appropriate alternative,” they said. “It’s time for Anthem and CommonSpirit to put patients before profits and come to an agreement that continues in-network coverage for facilities such as Mercy Hospital in our communities.”

However, officials also recognize, much to their chagrin, that they have relatively little leverage over the two independent organizations.

“I don’t believe we have any formal legal authority here, but we’re going to keep looking at it,” Colorado Attorney General Phil Weiser said during a visit to Silverton last week. “I’m really concerned based on what I’m hearing.”


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