Elevance Health shared plans to potentially penalize facilities that use care providers who aren’t in network with Anthem, a move that worries spine surgeons.
The policy, which would go into effect Jan. 1, focuses on 11 states and says facilities could face “an administrative penalty equal to 10% of the allowed amount of the facility’s claims that involve the use of nonparticipating care providers.”
Three spine surgeons discuss how this affects their specialty.
Note: These responses were edited for clarity and length.
Question: Elevance Health shared plans to potentially penalize hospitals and facilities that use out-of-network providers in 11 states. How could this move affect spine care in the short and long term?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: It’s very anti competitive behavior from an already embattled insurer. To penalize a hospital because physicians don’t take their insurance for any number of reasons is insanity. Physicians have the right to take whatever carrier they want as an independent physician, and I think there’s going to be several potential outcomes from this.
More physicians will drop Blue Cross because of its anti-competitive behavior. Fewer physicians will then go to hospitals that are going along with the penalization of physicians that don’t take Blue Cross, and I think those hospitals will either need to hire more physicians and will drive up their costs, or they’ll need to break their contracts with Blue Cross.
The outcome is that Blue Cross will end up harming itself. If physicians don’t take their insurance, because of this anti competitive behavior, then their patients will lose access to their doctors, and it will drive up their out-of-pocket costs. Some patients can’t afford that, but a lot of patients will opt to maybe even pay out of pocket until they can go to open enrollment and then drop Blue Cross as a carrier. Blue Cross will then lose the premiums from those patients and then have to raise the premiums on the remaining patients, which will again drive up costs and drive patients out of their networks. It’s a very foolish behavior that’s going to only end up hurting their bottom line, and I think, drive us faster and faster to a single payer system.
Philip Louie, MD. Virginia Mason Franciscan Health (Seattle): This one could be a bit complicated. Let me look at it from a couple different lenses here.
This policy is publicly framed as a cost–quality lever, but on the front lines I think it’s really a workflow/incentive/access stress test. From the surgeon’s perspective, I think it will expose some of the fragile aspects of our daily operations, like where network gaps, anesthesia coverage, and scheduling logistics often collide. If I put my business hat on, this really does feel like a real-time experiment in how payers use economic pressure to reshape behavior across the care continuum.
Ultimately, I think that spine programs/groups that own their ecosystem, with aligned anesthesia, standardized vendors, ASC integration, disciplined booking, and shared data transparency, will demonstrate how to absorb this shock and even leverage it as a differentiator in value-based negotiations. And those that don’t may feel some of the consequences fairly early on: more friction, cancellations, and the slow, steady pull towards consolidation.
We can’t let policy shifts or payer tactics define our care pathways. As surgeons, we need to keep the main thing the main thing, which is indications and carpentry. But, we need to partner with our administrators and leadership to also build operational and economic guardrails that protect patient access and allow our teams to deliver high-value spine care in a long-term sustainable way.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): An interesting turn of events for a number of insurers, who definitively want in-network care to be administered to the designated physicians. Does this latest punitive move not reflect the basic tenants of the ACA and restricted ‘inclusivity’ that was originally designed when enrollment began. It certainly limits both physician and patient choosing for second opinions/care and the ability to seek out the best care possible.
It is literally a reprising deterrent for both patients and health systems, disallowing patient access to specialty medicine. Elevance Health has many health plans which potentially penalize hospitals and other contracted facilities that use care providers who are not in-network with its Anthem Blue Cross Blue Shield commercial plans in 11 states. This move is another form of scrutiny and restriction.
Under the policy, finalized Oct. 1 and effective Jan. 1, facilities could face “an administrative penalty equal to 10% of the allowed amount of the facility’s claims that involve the use of nonparticipating care providers.” Placing additional cost to a decade long, skyrocketing premiums, fading portability and more dictatorial restrictions, seems contrived on its face.
