Tuesday, February 01, 2005

Some Thoughts on Anthem vs Premier

Here in southwest Ohio, Anthem is one of the two 800 pound gorillas in the medical insurance area, particularly in the group field (the other being United Health Care).

In the Dayton area, Premier Health Associates includes two hospitals and about 100 doctors.

Recently, the contract between these two entities expired and, failing to find a compromise position, they parted ways.

The immediate effect of this fall-out was that one of the areas two best hospitals is no longer in the Anthem network, and a slew of specialists are also now “off limits.”

Which brings me to two seemingly unrelated observations:

First, it’s always interesting to me when someone says that their insurance carrier won’t “let them” receive some particular medical treatment. Last I looked, the only thing an insurer can do to dissuade you from undergoing treatment is to threaten not to pay for it. No carrier can actually prevent someone from seeking treatment. Even for out-of-network claims, many plans will cover at least a portion of the bill. And in an emergency, non-network claims are treated as in-network.

Second, I’m really surprised that the two players involved (Anthem and Premier) are still wrangling over this. Yes, the hospitals can afford to wait it out, but the physicians are really starting to hurt. Many (most?) people have health insurance through their employer, and have little – if any –say in which carrier that employer chooses. So more and more folks have to switch docs, leaving Premier’s physicians with a shrinking customer base (and that’s really what a patient load is: a customer base).

OTOH, surely Anthem sees a potential for other carriers -- whose contracts with Premier are still valid -- to step into the void, publicizing their on-going relationship with Premier. At some point, Anthem’s new business sales will begin to fall off, squeezing them, as well.

Of course, the folks who are really getting hurt here are the insureds, who signed up with Anthem believing that they would see no changes in providers. And as noted, it’s not as if many have a choice, or a voice, in the matter.

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