MARIETTA —The largest healthcare system in Georgia is having a spat with the state’s biggest health insurance company, and it could mean bad news for some patients who purchased insurance on the individual exchange.
WellStar Health System, with its 11 hospitals, 225 medical office locations and specialized health centers, is set to stop accepting patients using Anthem, formerly known as Blue Cross Blue Shield of Georgia, Feb. 4.
To be clear, this change only affects patients who receive coverage through the Affordable Care Act. If you have employer-provided healthcare from Anthem/Blue Cross Blue Shield, you will not be affected.
Yet it means self-employed patients like Martha Sanderson of west Cobb could be stuck paying out-of-network costs or making a long drive to see a doctor.
Sanderson said she recently tried to make an appointment for March and was told she would no longer be covered.
She said having to drive farther for a regular doctor’s appointment is the least of her worries.
“The bigger concern is that if someone in Cobb County needs to have some type of surgery, they have to go out of their area to have it,” she said. “We watched WellStar grow for 25 years. If I need some form of surgery, I have to go out of county for that. I don’t have a hospital to go to without a 45-minute drive.”
WellStar declined to say how many patients received treatment under this product in 2018, instead only communicating through press statements, including this one from WellStar spokeswoman Nicole Gustin.
“On August 8, 2018, Anthem/Blue Cross Blue Shield notified us that they were terminating WellStar as a participating provider in their Pathways product available through the Affordable Health Care Exchange. We immediately disputed this action, and are pursuing all contractual rights we have to resolve this issue. But it appears unlikely that WellStar will be participating past February 4, 2019.
“We understand how difficult this is for patients who choose WellStar hospitals and physicians. WellStar was not able to notify Anthem members of this change, as we do not have a listing of individuals who signed up for this Anthem plan.
“This in no way affects patients who have employer-provided healthcare through Anthem/Blue Cross Blue Shield. WellStar’s overall contract with Anthem remains intact. All WellStar patients covered under Anthem products, other than Pathways, will continue to have access to the entire WellStar Health System.
“For questions about your Affordable Health Care Exchange coverage through Anthem/Blue Cross Blue Shield, call 1-800-318-2596.”
Anthem released the following statement:
“Helping to ensure consumers have access to individual health plans that offer greater affordability and access to quality health care remains our focus at Anthem Blue Cross and Blue Shield. Unfortunately, we could not come to an agreement on affordability with WellStar, which chose not to continue to participate in Pathway as other providers have. Anthem has a broad network of hospitals and doctors in the Georgia Pathway network, and we are working with members to transition them from WellStar physicians to other high-quality providers.”
Unless and until the two parties can come to an agreement, patients like Sanderson and potentially thousands of others will be left searching for alternative health care options.
“I don’t know what will happen,” she said. “I won’t know until Feb. 4, I’m assuming. I guess I'll just drive a long way in our lovely traffic if I have to go to the hospital. I thought a hospital was something you were supposed to take pride in your county.”
David Bottoms, senior vice president of benefits at Marietta-based insurance firm the Bottoms Group, said the failure to reach an agreement could be especially harmful because open enrollment ended last month and many patients like Sanderson bought in because WellStar was included in the plan.
“Continuing negotiations are a complicated thing, and they happen regularly, so that part of it is not surprising,” he said. “The odd thing about this situation is the timing of it. Obviously, the open enrollment period for the individual marketplace was in the fall. A lot of people in the exchange purchased a Blue Cross Blue Shield policy because they thought they would be able to use WellStar. Now to find out less than a month into the year that relationship could be severed is surprising.”
Bottoms said those patients are effectively locked into their plan until January of next year, so they can’t simply switch to another carrier that accepts WellStar.
For now, the two companies are locked in a high-stakes game of chicken, and Bottoms said Anthem may have the advantage for the time being.
“They were able to use WellStar’s ‘in-network’ status to drive enrollment in the fall, and now, if WellStar does not agree to lower their costs, which I am sure is what Anthem/BCBS is asking WellStar to do, patients with Anthem/BCBS coverage will have to go to other providers with other health systems, who, on the balance, are likely to have lower costs for the services provided, yielding lower claims for Anthem/BCBS to pay,” he said.
Bottoms added that the biggest losers in the arrangement are likely to be the patients who bought insurance thinking they could go to their local doctor, only to find out the terms have changed.
Bottoms said that there may still be hope for a deal before Feb. 4.
“Sometimes with these negotiations, it comes down to the 11th hour and a deal gets worked out,” he said. “I’m not privy to those discussions, but hopefully there are open lines of communication between the parties, and hopefully there will be a resolution.”