Wednesday, December 31, 2003

Dispute could leave Anthem users in lurch

By Matt Leingang
The Cincinnati Enquirer

A contract dispute between Cincinnati's largest hospital group and the region's biggest health insurer shows little sign of being resolved by tonight's deadline, meaning health services for thousands of residents could be disrupted.

At midnight, a contract between the Health Alliance of Greater Cincinnati and Anthem Blue Cross & Blue Shield is set to expire. Both sides have been negotiating all week, but those talks apparently have broken down.

Anthem officials are publicly downplaying any hope that a deal can be reached; no meetings were scheduled today. The insurance company rejected an extension of the current contract, according to the Health Alliance.

Starting Thursday, Greater Cincinnati residents covered by Anthem may find themselves unable to access services from Health Alliance hospitals, which include Christ, University, Jewish, St. Luke and Fort Hamilton hospitals.

Also, people covered by Anthem who have doctors with the Alliance Primary Care physician group might have to choose a new doctor for their basic health-care needs.

Anthem provides health insurance to 350,000 people in Greater Cincinnati, but it is unclear exactly how many people would be affected by a break with the Health Alliance.

Anthem warned members earlier this month that the Health Alliance might not be part of Anthem's health network in 2004. Some people also have received a letter from the Health Alliance. Anthem plans another mailing to members this week.

People with Anthem insurance may be able to stay with Health Alliance hospitals and doctors if they have out-of-network benefits, but higher costs would apply - meaning patients would have to pay higher co-payments and deductibles.

Health Alliance officials are working on ways to help patients offset those costs, said spokeswoman Gail Myers.

The contract dispute comes down to money. The Health Alliance wants higher reimbursement rates for its doctors and services; Anthem says the Health Alliance is asking for too much.

Neither side would give specific numbers.

Earlier this year, Health Alliance officials said they needed to pump about $500 million into new equipment and facility improvements in the next five years to keep up with rapidly advancing medical technology.

For the past several years, tight reimbursement rates from big insurers have limited the system's ability to reinvest in services, Health Alliance officials said.

What the Health Alliance is seeking is not out of line with market forces nor is it radically different from agreements with other health insurance companies, Myers said.

"We're a not-for-profit organization, and we're simply looking to cover the cost of the care that we provide and to have enough of a margin to replace equipment and advance technology," Myers said.

But what the Health Alliance really wants, according to Anthem, are "new terms and conditions that would restrict competition and therefore increase the cost of health care," spokesman Joe Bobbey said.

Local doctors say the contract dispute has been a burden to them and their patients.

Dr. James Wendel is part of a group of obstetricians that is caring for 22 pregnant women with Anthem insurance who are scheduled to give birth in January at Christ Hospital, which is part of the Health Alliance.

In addition, Wendel's group has 17 Anthem patients scheduled to have elective surgery at Christ next month.

"Where are we supposed to go?" said Wendel, who is with Mt. Auburn Ob/Gyn Associates. "Hospital capacity is already tight in Cincinnati. Where are other hospitals going to get the room for our patients?"

Other area hospitals say they will do what they can.

"We only have so many beds and so many nurses to take care of people," said Joe Kelley, spokesman for TriHealth, which includes Good Samaritan and Bethesda North hospitals.

Any scheduling delays could hurt patient care, other doctors said.

Dr. Thomas E. Shockley Jr., a surgeon with Orthopaedic Diagnostic and Treatment Center in Cincinnati, said he has "numerous" Anthem patients scheduled to have surgery at Jewish Hospital - another Health Alliance affiliate - in the next few weeks.

"We need to notify our patients that they no longer can go to the facility of their choice," Shockley said.

"This could delay their treatment and needed care."


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