New Anthem Policy

New Anthem policy will steer patients to less expensive free-standing imaging centers

Starting in March, Virginians insured by Anthem must seek imaging services at free-standing facilities instead of hospital-based ones.

Virginia Anthem spokesman Scott Golden said in an email statement the policy includes MRIs and CT scans outside of emergency situations. Reimbursements will be denied in hospital settings if there’s an alternative within 30 miles, and if no clinical reason can be given that a hospital setting is needed.

“The clinical guideline gives members an opportunity to save up to hundreds of dollars for each imaging test,” said a statement emailed by Golden. “It also helps health plans keep premiums more affordable.”

The policy, called the Imaging Clinical Site of Care Review Program, was rolled out in Indiana, Kentucky, Missouri and Wisconsin on July 1, and in Colorado, Georgia, Nevada, New York and Ohio on Sept. 1. It will be implemented in Virginia, California, Connecticut and Maine on March 1.

Physicians will be given lists of free-standing facilities that provide such services when they order a test. The policy focuses on MRIs and CT scans, not X-rays or mammograms.

Spokeswomen from Sentara Healthcare and Bon Secours Hampton Roads said they have posed questions regarding the policy to Anthem and are awaiting word from the company. Both said it would be premature to comment on the impact on the hospital systems and their patients.

Chesapeake Regional Healthcare issued a statement expressing concern about the loss of access to Anthem patients, “and the disruption to their continuity of care when scans are performed outside of their preferred hospital system.”

Children’s Hospital of The King’s Daughters said Anthem’s official notification is expected in December, so more information is expected then. However, public spokeswoman Ridgely Ingersoll emailed a statement saying CHKD has pediatric radiologists trained to treat its unique patient base of children.

“For example, many children require sedation for MRI scans, and CHKD offers this,” the statement read. Also, CHKD uses pediatric radiology protocols using the lowest possible dose of radiation based on each child’s age and size.

The Anthem policy is the latest salvo in the competition between independent facilities and large hospital systems. Hospitals have long argued against getting rid of what’s called certificates of public need in Virginia, which require facilities to apply for approval to open a medical facility. Hospitals have argued such a move would allow independent facilities to “cherry pick” lucrative services, one of which is typically imaging services. Hospitals have said it would undermine hospitals’ revenue stream, and ability to subsidize unprofitable services, such as trauma and emergency care.

Julian Walker, vice president of communications for the Virginia Hospital & Healthcare Association, said in a prepared statement the Anthem policy is overly restrictive: “Decisions about advanced imaging tests that patients need to diagnose and treat an illness or injury should be made with patient interests in mind. Decisions by insurers to restrict where patients are permitted to receive a necessary medical procedure fail to meet that standard. Such prohibitions can result in patients being steered away from a hospital to an insurer-preferred freestanding facility that may lack the capability to quickly assess a patient’s condition.”

His statement said the policy could lead to care fragmentation “by requiring a patient to travel farther and visit multiple locations for treatment rather than receiving care in an integrated setting.”

But in an increasingly consumer-driven world, cost is becoming a key factor. And if people won’t search for the least expensive services, insurers are stepping in to steer them in that direction. Virginia Health Information, a nonprofit health data organization created by the state legislature, has a price transparency tool on its website that compares costs of hospital-based versus imaging in a doctor’s office.

For the eastern region, which includes Hampton Roads, a CT scan of the abdomen in 2015 cost $350 in a doctor’s office, compared to $1,168 in an outpatient hospital setting. An MRI scan of the knee cost $417 in a doctor’s office, compared to $1,403 in an outpatient hospital setting. An MRI back scan cost $377 in a doctor’s office, compared to $1,553 in a hospital.

Golden’s statement said Anthem’s primary concern is to provide access to quality and safe health care: “We are also committed to reducing overall medical cost where possible when the safety of the member is not put at risk.”

By Elizabeth Simpson
The Virginian-Pilot
Oct 4, 2017