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Anthem’s Battle With Doctors Shows Risks for Surprise-Billing Fix

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Doctors fighting a reimbursement battle with one of the biggest U.S. health insurers want to make sure that ending surprise medical bills doesn’t come at the expense of their pay.

Anthem Inc. cut payments to some California physicians last month as part of what it called a routine adjustment to fees. Physicians say the move was the result of a 2016 state law that keeps patients from being forced to pay the difference when insurance companies and care providers clash over health costs.

California is one of several states that have acted to halt so-called surprise medical bills, an effort that is gaining traction on the national level. It limits how much doctors can collect when they don’t have a contract with a patient’s insurance plan, setting a benchmark payment rate for ending billing disputes.

(Related: ‘Surprise Medical Bill’ Witnesses Clash Over Binding Arbitration)

Anthem, which runs Blue Cross Blue Shield health plans in 14 states, said its reimbursement changes were unrelated to California’s law and that it increased pay for some clinicians.

Putting a stop to surprise bills has become a priority for the Trump administration. The House Committee on Energy and Commerce will consider legislation that mirrors California’s approach in a hearing beginning on Wednesday. Doctors are lobbying lawmakers not to use California’s overhaul as a template, saying they’d bear the brunt of such a change.

Large unexpected medical bills generally result from cases where patients get care outside their insurer’s network, often in emergencies. Anthem’s reimbursement cuts in California focus on physicians who work primarily in hospital settings, including pathologists, radiologists and anesthesiologists, doctors said. Anthem disputes that the anesthesiologists were affected.

“Insurers are terminating long-standing contracts with physicians or mandating significant rate cuts,” the California Medical Association wrote in a July 10 letter to U.S. lawmakers. Cuts to hospital-based physicians could threaten patients’ access to care, the group wrote.

Anthem’s goal is to “promote equitable reimbursement for providers and support an adequate number of providers in our network while also addressing the need for our consumers to have access to quality, affordable health care,” spokeswoman Joyzelle Davis said in an email.

Market Forces

Medical providers can set their list prices as high as they like, and physicians who primarily practice in hospitals have some of the highest. For example, before discounts negotiated with health plans, anesthesiologists charge almost six times the rate paid by Medicare for their services, according to a 2017 analysis in JAMA.

Doctors opposed to making California’s benchmark-rate policies a nationwide blueprint worry that they doing so wouldweaken their bargaining power and force them to shoulder a disproportionate share of the burden for reducing health costs.

Bob Achermann, a lobbyist who represents California pathologists, said those specialists were seeing Anthem’s rates for some services cut by 50%. He said the reductions could push some doctors to leave the insurer’s network.

California’s new law may already be reshaping the market. The California Medical Association said several other health plans it didn’t name had cut payments or torn up existing contracts, mostly affecting anesthesiologists.

Anthem said its rate update increased pay for some clinicians, including primary-care doctors and behavioral-health providers. The company also said the changes weren’t limited to California but didn’t elaborate.

The College of American Pathologists said Anthem’s pay cuts have affected pathologists in Alaska, California, Indiana, Missouri and Ohio, spokesman Charles Fiegl said. The American College of Radiology found no evidence its members were affected nationally, according to spokesman Shawn Farley.

Doctors in New York, which has a surprise-billing law seen as more favorable to care providers than California’s, haven’t seen similar cuts from Anthem, according to spokeswoman Roseann Raia of the Medical Society of the State of New York.

Access Question

Patient groups, including the lobbying arm of the American Cancer Society, support the use of benchmarks to resolve billing fights. The group that pushed for California’s surprise-billing law says it hasn’t diminished access to care.

“The sky has not fallen in California,” said Anthony Wright, executive director of Health Access California. “Consumers can’t afford a surprise medical bill, nor can they afford premiums that have been jacked up because of monopoly pricing.”

About 30% of Californians reported getting an unexpected medical bill last year, and an average family health plan now costs almost 30% of typical household income in the state, according to Kristof Stremikis, director of market analysis and insight at the nonprofit California Health Care Foundation. That’s roughly similar to the national proportion.

“We know that health care costs in this country can come down, without harming access or quality,” Stremikis said.

Lawmakers say that whatever form a surprise-billing measure ultimately takes, patients should benefit — and bigger players shouldn’t get a windfall.

“If doctors are charging inflated rates, then they have to come down,” Rep. Anna Eshoo, the California Democrat who chairs the Energy and Commerce Health Subcommittee, said at a hearing July 11.

“If insurers save money with our bill, then those savings should be passed on to patients in the form of lower premiums,” she said. “No one should profit from our bill, not insurers, not doctors, not hospitals.”

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