Colorado: Anthem/UCHealth squabble leaves a friend of mine (& thousands of others) out in the cold

I first wrote about Laura Packard here 3 1/2 years ago when she was first diagnosed with Hodgkins, though I've known her personally for a good 15 years or so. When she was diagnosed, her outlook was bleak; fortunately, she has since recovered and is now doing great:

In the spring of 2017, I was diagnosed with cancer (stage 4 Hodgkin’s Lymphoma). After a grueling 6 months of chemotherapy and a month of radiation treatment, I am in remission. For now. Hopefully forever.

The Affordable Care Act saved my life. But all the time I was fighting cancer, I had to fight my own U.S. Senator and my President in order to keep my health insurance. The day after my first chemotherapy session, the Republican House voted to dismantle the ACA. The “skinny repeal” of Obamacare was voted down in the Senate by one vote a couple days before my 7th chemo session. And the day after my 15th radiation session, I was thrown out of my (former!) U.S. Senator’s public forum for asking him about his health care record.

Unfortunately, via FOX Denver, KDVR, my friend may once again be subjected to the insanity of our healthcare system:

Denver-area Anthem customers on Colorado exchange forced to switch doctors

DENVER (KDVR) — Laura Packard was diagnosed with stage 4 Hodgkins-Lymphoma cancer in 2017. The 44-year-old moved from Nevada to Colorado in 2019 for one reason: the state’s heath insurance exchange that provides affordable options to individuals who otherwise can’t get coverage.

Doctors at UCHealth have continued to treat Packard to make sure she stays cancer-free.

“I can’t go without seeing an oncologist. I’ve only been in remission for a couple of years,” said Packard, who was devastated to learn her insurance carrier Anthem and UCHealth couldn’t reach an agreement for 2021.

“They know you and what you’ve been through and I think if you look at national rankings, it’s pretty clear where people fall. UCHealth has expertise that nobody else offers,” said Packard.

The contract dispute between Anthem insurance and UCHealth means Anthem patients in metro Denver will have to switch doctors if they want to stay in-network beginning Jan. 1, 2021.

Apparently this particular issue is a localized one:

Colorado’s Department of Insurance confirmed to the FOX31 Problem Solvers that Anthem’s in-network plan still includes UCHealth doctors and hospitals for the rest of Colorado; only metro Denver has been replaced by a plan that uses HealthOne doctors and facilities instead.

“We can’t dictate who they (Anthem) contract with, only that they have an adequate network,” said Vincent Plymell, the assistant commissioner for the Colorado Department of Insurance.

"An adequate network" is the key to this issue.

According to this 2015 American Medical Association brief:

• The Affordable Care Act (ACA) requires that qualified health plans maintain provider networks that are sufficient in number and types of providers to ensure that all services, including mental health and substance use disorder services, are accessible to enrollees without “unreasonable delay.”

• Provider networks of exchange plans also must include “essential community providers,” which predominantly serve low-income and medically underserved individuals.

• A plan’s provider directory must be accurate and available online and in hard copy upon request. Plan provider directories are also required to identify providers that are not accepting new patients.

• In Medicare Advantage, plans must meet network adequacy criteria related to minimum number of providers and facilities, and maximum travel time and distance.

This all sounds reasonable, except that, as the brief goes on to note:

• The term “unreasonable delay” is not defined in the ACA or related regulations. Therefore, there is much variation in how the “without unreasonable delay” standard is implemented by health plans and states.

• Addressing the network adequacy of health plans offered on federally facilitated exchanges, the Center for Consumer Information and Insurance Oversight (CCIIO) stated that it intends to collect plan provider lists and review them to determine whether providers are available without unreasonable delay. CCIIO also stated it will eventually develop time and distance or other standards to guide network review.

• In state-based exchanges, there have been only limited efforts to adopt comprehensive network adequacy standards or requirements.

• Some states rely on health insurers attesting to their own network adequacy requirements, whereas others use private accreditation to evaluate network adequacy – either the Health Plan Accreditation program of the National Committee for Quality Assurance (NCQA) or URAC Health Plan Accreditation Program. However, NCQA and URAC have stressed that their accreditation should not be viewed as a substitute for an insurance commissioner’s oversight of the adequacy of a network.

• Provider directories may contain inaccurate or misleading provider information, preventing patients from making informed decisions and creating misperceptions of the networks’ adequacy.

• Changes to existing insurance products to rely on increasingly narrow and tiered networks are being implemented without adequate or meaningful notice to patients or physicians.

• Insurers may use inaccurate or misleading data to select network physicians, or evaluate physicians based on cost alone, which undermines patient access to quality care.

• Patients who need to seek care from out-of-network providers face the potential of significant out-of pocket costs.

I've highlighted the bullets above which seem to be most relevant here. I have no idea how rigid "network adequacy requirements" are or how well they're enforced in Colorado specifically (which uses a state-based exchange). Perhaps they've beefed up those requirements since this brief came out five years ago. What I do know is that vague requirements to avoid "unreasonable delay" and include "adequacy standards" don't do much good if a particular patient needs a particular doctor or facility to be in their network in order to receive optimum (or even acceptable) treatment.

Plymell said Anthem met state requirements when it ensured its contract still included an in-network provider, such as HealthOne.

“They (Anthem) were able to bring the premiums down in the Denver area by over 20 percent and the majority of that was due to negotiated rates that had with HealthOne and that’s a big concern for us as well, is keeping premiums down,” said Plymell.

The problem with this, for someone like Laura, is obvious:

“They claimed there would be some kind of great savings but what good it is for people like me if we save a few dollars a month in premiums and then have to pay all that to see our doctor out-of-pocket?” said Packard.

And it's not just Laura, of course:

The Problem Solvers have spoken to other patients besides Packard who don’t want to switch to HealthOne but can’t afford the out-of-network fees UCHealth would now require.

“If my cancer recurs and I need the kind of treatment that I can only get at UCHealth, that is hundreds of thousands of dollars and I could die without that treatment,” said Packard.

Ironically...

Some Anthem patients can apply for what’s called a “Continuity of Care” if they have an acute condition. But Laura Packard said she doesn’t qualify because her cancer is in remission and that option requires approval from Anthem and usually only extends care through UCHealth for 90 days.

Anthem would not tell FOX31 how many patients are affected in metro Denver by the switch to HealthOne.

Anthem may not want to reveal how many people are impacted, but I can hazard a pretty good guess. Anthem has two divisions in Colorado's individual market: HMO Colorado, Inc. and Rocky Mountain Hospital & Medical, which I think is their PPO division and which only offers off-exchange policies on the indy market. According to their 2021 rate filings, Anthem had around 52,000 Individual Market enrollees total this past spring.

I also know, from Connect for Health Colorado's 2020 Open Enrollment Period report, that around 22,700 residents of Denver County enrolled in ACA exchange policies this year, though this includes all 8 carriers, not just Anthem. There's also some amount of net attrition over the course of the year; normally a good 20% or more of those who enroll during Open Enrollment have dropped their coverage by the end of the year, although due to the COIVD pandemic retention has been higher this year; let's call it perhaps 15% or so, which would bring the potential total down to around 19,300 people.

Statewide, Anthem has around 28% market share on the CO indy market, but I have no idea if that's proportionate in Denver County specifically. Assuming it is, that would mean perhaps 5,400 enrollees who may be impacted by this development. My guess is that it's higher there, so I'd guess we're talking about somewhere between 5,000 - 19,000 people. Granted, not all of them need to have UCHealth in their network as Laura does.

UPDATE: OK, apparently the "shrunken network" this impacts is larger than I thought:

The Pathway Essentials network will be an HMO narrow network, available in the following counties: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Clear Creek, Elbert, Gilpin, Jefferson and Park.

If you leave out Boulder, which I understand isn't impacted in spite of being listed above, a total of 85,103 residents of those counties enrolled in the CO ACA exchange last spring, or roughly 51% of the total, so the actual number of enrollees potentially impacted probably ranges between around 22,000 - 44,000 people. If it turns out Boulder is impacted as well, the low end of the range is potentially up to several thousand more people.

As for the third bullet I highlighted:

A spokesman for UCHealth said the hospital chain wasn’t notified until this fall that its facilities would no longer be part of Anthem’s plan for customers in metro Denver, which is why it doesn’t have an alternative plan.

The "good" news here (such as it is) is that thanks to Connect for Health Colorado's Open Enrollment deadline being a month later than the federal exchange (January 15th instead of December 15th), Laura and others still have a month to switch from Anthem to a different carrier if Anthem and UCHealth don't manage to work something out and she has to do so.