March 07--Premier Healthcare has lost patients and even some doctors since leaving the Anthem network more than four months ago, but the physician group's recent negotiations with the insurance giant have been encouraging.
"Over the last four to five weeks, we've had more discussions about the key issues than we had previously," said Dr. Wes Ratliff, president of Premier Healthcare, a physician group that serves about 100,000 patients at six sites in Bloomington. "I think some progress has been made."
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Ratliff said not enough differences have been settled to sign a contract, but he's hopeful that -- if the two parties can keep the lines of communication open -- enough common ground can be found to end the impasse.
"I'm hopeful that we'll reach an agreement with Anthem relatively soon, assuming we can continue the communication we've had over the last few weeks," he said.
Anthem spokesman Tony Felts said Anthem Blue Cross and Blue Shield still would like to see Premier Healthcare rejoin the Anthem network.
"The lines of communication have been open at all times, and there has been periodic communication," he said. "Unfortunately, Premier's initial contract proposal would result in a 14 percent increase -- $10.4 million -- over the next five years. That's money that would come directly out of the pockets of businesses and consumers in Monroe and surrounding counties."
In the meantime, Premier has taken steps to keep patients from leaving the fold, such as reducing office visit down payments to $25 and reducing the total cost of office visits for those using its out-of-network prompt pay program.
"We realize this is placing a significant burden on our patients, so we are doing all we can to make their out-of-network costs more palatable," he said.
Feeling the pain
Ratliff confirmed that two physicians will soon be leaving Premier Healthcare, but added that he does not know for sure whether it's because of the situation with Anthem. He admitted Premier's physicians have been seeing fewer patients, but wouldn't say how much the group's patient volume has shrunk.
"We had an initial drop-off as expected, but it's been pretty stable since then," he said. "There's no question that some Anthem patients are either waiting on the sidelines until we're back in network, or are now seeing other providers. If patients have temporarily gone somewhere else, we hope they eventually come back."
Amanda Roach, spokeswoman for IU Health Bloomington Hospital, said between Nov. 1 and May 1, only one of the 11 providers that have joined IU Health Southern Indiana Physicians -- the hospital's provider group -- has previously worked at Premier.
"Any new providers who join IU Health Southern Indiana Physicians are recruited based on the needs of our patients," she said. Roach added that physicians and nurse practitioners at IU Health Southern Indiana Physicians have been seeing new patients at an impressive rate, not only since the Nov. 1 impasse but over the past year.
"We attribute our growth to both the need for access to primary care in our region and to the reputation and expertise of our physicians."
For Dr. Jim Calli, an independent Bloomington cardiologist who is not part of any physician group, the impasse has been like a performance-enhancing drug for his practice.
"I'm getting an avalanche of new patients," he said. "My patient volume has gone up 30 to 40 percent. I was seeing three to four new patients a day, but I'm now limiting it to two new patients a day."
When Calli first sees these new patients, he jokingly tells them he knows it's his sterling reputation that has brought them into his office.
"But most of them tell me it's because they're disgruntled about the Premier/Anthem insurance situation," he said with a laugh. "I'm really not trying to build my practice anymore. It was large before, but now it's much larger."
Calli is among those who feel that doing battle against Indiana largest insurer is a quixotic quest.
"I don't know why they (Premier) are digging their heels in, because they can't win," he said. "It's too bad, because Anthem pays the lowest reimbursement rates of any insurer, rates that are even below Medicare."
When asked why Premier has not waved the white flag, Ratliff said, "Maybe because it's important. We knew from the beginning that this would be a difficult negotiation, and it has been. But the encouraging thing from our perspective is the increased communication we've had with Anthem over the past few weeks."
When asked if Anthem is escaping unscathed, or whether some of its employers or patients have dropped Anthem in favor of another insurer, Felts didn't answer the question directly.
"We are listening to our customers, and we appreciate their patience and their support," he said. "Their concerns about health care costs are the key factor in this negotiation."
For many Anthem-insured patients, the Premier-Anthem separation has been not only costly, but confusing and frustrating.
For more than a year, David Carrico has relied on medication to treat his rheumatoid arthritis delivered through monthly infusions at the Internal Medicine Associates infusion center on Landmark Avenue.
He has Anthem insurance through his job as Centerstone's director of adult services for the Bloomington region, but after Premier Healthcare left the Anthem network Nov. 1, Carrico didn't want to pay the out-of-network rate at IMA, which is a division of Premier Healthcare.
"I started going to Monroe Hospital for the infusions so I could be in-network," he said, referring to the fact that the hospital portion of his bill would be charged at an in-network rate because Monroe Hospital is in the Anthem network. "But when I got the bill, it was double what I'd been paying at IMA. I wished I had researched it ahead of time."
He said the facility charge for each half-hour infusion -- administered into a vein in his arm -- was about $9,000 at Monroe Hospital compared with $4,000 at IMA. He said his out-of-pocket cost per infusion was about $1,000 at in-network Monroe Hospital compared with $350 at out-of-network IMA -- resulting in a $650 hit to his wallet.
Carrico said his financial pain was assuaged a bit by the fact that he qualified for a co-pay assistance program offered by the drug manufacturer, but he still doled out considerably more for his infusions.
Ratliff is not surprised by Carrico's story.
"You can expect to pay 200 to 300 percent more for the same procedure performed in a hospital than you would for the same procedure done in an outpatient facility," Ratliff said. "That's difficult for many patients to understand, but that's the way it is."
Felts said the reason hospitals charge more is that they have larger overheads and provide medical care 24-7.
Carrico said he's now found an in-network rheumatologist who will give him the infusions in his office.
"Because I'll be getting the infusions in an office setting, it will cost me considerably less," he said. "I can't afford $1,000 out of pocket every month."
But Carrico is upset that the split between Premier Healthcare and Anthem has not only taken hard-earned money from his pocket, but forced him to stop seeing a physician, Dr. Narcisa German, he trusted and felt comfortable with.
"This impasse is getting in the way of me choosing the doctor I want," he said. "I'd been seeing Dr. German for four to five years. She is a good doctor and I like her. I wish Premier and Anthem would come to terms so I could keep her as my doctor."
Carrico said he knows several others who feel equally powerless concerning their health care choices.
"Anthem is a big player in Indiana and can throw its weight around," he said. "But it's people like me who get the shaft."
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