Oct. 1 update: As of Tuesday, most Northeast Georgia Health System facilities and doctors are out of network with insurance provider Anthem, according to the NGHS website.
NGHS and Anthem had been engaged in a monthslong negotiation over the five-year contract, which expired Sept. 30. The two parties did not reach an agreement before the contract expired.
NGHS facilities currently out of network with Anthem are all Northeast Georgia Medical Center hospitals; all Rehabilitation Institute, Imaging Center and Cancer Center locations; Hospice of NGMC; New Horizons Limestone and Lanier Park; Sleep Disorders Center; Laurelwood; all Urgent Care locations; all locations of The Heart Center of NGMC; and most Northeast Georgia Physicians Group locations. NGPG’s family medicine and internal medicine practices in Buford, Cumming, Dacula and Hamilton Mill are not affected by this negotiation and are still in-network.
Other local health care providers, including the Longstreet Clinic and Gainesville Surgery Center, an outpatient surgery facility, are still in network with Anthem.
“Despite our determined efforts to protect in-network access for patients, Anthem continues to demand terms that would negatively impact the way patients receive care at NGHS,” Steve McNeilly, vice president of managed care with NGHS, said in a statement. “We have offered Anthem a proposal that is fair to both parties, yet they refuse to work with us in a meaningful way.”
According to a statement from Anthem, the insurer has some concerns about rising costs at facilities that NGHS acquires.
“These increases place a significant burden on consumers because any substantial price increase in the services at these facilities would be directly reflected in increases in medical expenses covered by employer-sponsored group health plans, as well as to member premiums and cost share amounts,” the statement reads. “This has an even greater impact on public and private employers who are self-funded and pay for medical services directly. What NGHS has proposed up until now is simply not sustainable for our members.”
McNeilly told The Times in September that NGHS was asking for a single-digit rate increase from Anthem, but the insurer was requesting that NGHS take rate cuts.
Negotiations between NGHS and Anthem will continue.
“We’re continuing to work hard to come to an agreement that continues to give you access to affordable care — and also makes sure that NGHS is compensated fairly,” the Anthem website states. “Our members are our top priority, so we’re hoping to sign a contract soon so you can regain access to in-network care from NGHS.”
The NGHS website also states that negotiations will be ongoing: “We will continue to fight to restore in-network access to the care you know and trust, but no one can predict how long that may take.”
According to a statement from NGHS, patients will still have in-network access to emergency rooms and should visit the nearest one if needed.
“You will receive in-network treatment until you are stable. At that time, you will have the choice to continue care with us at your out-of-network benefit level or to be transferred to a facility that remains in-network with Anthem,” according to the NGHS website.
Patients can call the number on the back of their Anthem card to see if they qualify for out-of-network benefits. According to the Anthem website, people who are in active treatment for a condition, are pregnant or have a terminal illness may qualify for continuity of care.
For questions about out-of-pocket costs for a scheduled procedure or test, patients should call the NGMC Patient Access Office at 770-219-7678.
Blue Cross and Blue Shield became Anthem Blue Cross and Blue Shield in Georgia in January, and negotiations began later that month.
Tom Hensley, president of Fieldale Farms, said the company has no plans to switch insurance providers after working with Anthem for 40 years.
“It’s unfortunate that they did not reach an accord,” Hensley said. “... We’ve been with Anthem a long time, and we’re confident in their ability and they’ve done a great job for us. It all boils down to money, of course.”
Hensley said he hopes an agreement is reached soon, and he is disappointed that the negotiations have been dragging out over profits.
“They’re dealing with people who work the chicken lines at Fieldale Farms who pay these bills,” Hensley said. “… It’s local people that are paying these bills, not some foreign insurance company. I think that’s being lost in translation.”
Sept. 30 update: With just hours to go Monday night, the health system and Anthem had still not reached an agreement in the dispute that could affect access to care for many local residents. An announcement on the outcome is expected early Tuesday.
Original story: A Sept. 30 deadline is fast approaching for Northeast Georgia Health System and Anthem to reach an agreement to keep to keep the facilities in network for the thousands of local residents with the insurer.
More NGHS patients have an employer-provided Anthem plan than any other plan, according to Steve McNeilly, NGHS’ vice president of managed care and integration strategies.
The health system and insurer have been negotiating their contract since Jan. 30 when NGHS first submitted a proposal for a renewal on the five-year contract, McNeilly said.
Two of the main points of disagreement are whether NGHS would need to renegotiate with Anthem when it acquires or opens new facilities and whether the rates paid by the insurer increase or decrease.
McNeilly said Anthem is moving to use a standard companywide contract that NGHS feels doesn’t take individual health care providers’ situations into account.
“It’s written by Anthem corporate attorneys, and it’s very one-sided favoring Anthem,” McNeilly said. “It takes away a lot of our ability to stand up for our patients and the things that we need to accomplish in the contract as a health system.”
However, Pam Stahl, the president of Anthem’s Georgia health plan, said that while Anthem likes to have some companywide consistency in its contracts, the insurance provider is also open to adapting the contract during the negotiation process.
“There’s significant flexibility, if a provider is different or a contract is different. Every city or part of a state is different, so we certainly have a lot of flexibility,” she said. “We have standard language we like to deal with to ensure we can administer, and then there’s flexibility as well.”
The growing health system has argued against renegotiating when it acquires new or opens new facilities.
Repeated negotiations would not be an efficient way to use time or resources, McNeilly said.
“We have been at this since Jan. 30 and we haven’t reached a deal. Could you imagine having to do this every year, or every six months?” he said. “Our employers and our patients would have absolutely no certainty of care in this market.”
That stipulation could be an issue if NGHS acquires Habersham Medical Center in Demorest. NGHS plans to invest $15 million in improvements at the Habersham hospital, with the hopes of acquiring it at the end of a five-year period.
“Anthem might at the end of the day decide they don’t want that facility in the network at all and refuse the contract,” McNeilly said. “We could actually own a hospital that Anthem could say they aren’t going to bring in to the network.”
Stahl said nothing has been decided about possible renegotiations. Her main goal, she said, is keeping care affordable for people with Anthem even as a health system may be making changes.
“When a hospital system expands or acquires new facilities, we generally see that rates go up in that area exponentially — for employers and consumers,” Stahl said, noting that she wants things to remain affordable.
The health system has requested a single-digit rate increase from Anthem, but the insurer is requesting that NGHS take rate cuts.
“A drastic rate cut would require us to have to change plans and potentially not invest in services and technology and revitalizing, for instance, the Gainesville campus and updating that,” he said.
Blue Cross Blue Shield became Anthem on Jan. 1. The company is based in Indianapolis.
Gary Hutchins, vice president of business development for CMA Agency in Gainesville, said drawn-out insurance negotiations like this aren’t that unusual, especially for larger systems and companies like NGHS and Anthem.
“The more negotiating leverage you have and the more volume you have in the community by way of covered lives, typically the negotiations get tougher and tougher and drag out longer and longer,” Hutchins, a former NGHS vice president of managed care services, said.
He said he has 30 years of experience working with both providers and payers, and an agreement is usually reached at the end — it can just be a stressful process for everyone involved.
One local employer that provides Anthem to its employees is Kubota. Phil Sutton, vice president at Kubota, said that if Anthem goes out of network with NGHS, employees will be left without the option to go to a nearby hospital if they need one.
“These people in Northeast Georgia, we don’t have reasonable alternatives in terms of a hospital. We can’t pick up and move. We can’t change hospitals,” Sutton said. “… For most people the closest nearby hospital is either the Northeast Georgia facility in Braselton and Gainesville, so where do they go? They don’t have options. My concern is taking care of our employees and making sure our employees and their family members have health care coverage in an in-network situation.”
Northeast Georgia Medical Center, for example, is less than five miles from Kubota’s Gainesville facility. Alternatives would include Northside Hospital Forsyth, about 34 miles away, or Northside Hospital Gwinnett, formerly Gwinnett Medical Center, about 33 miles away.
Sutton said about 2,700 local employees use the Anthem plan, and with family members included, about 5,000 people rely on the plan offered by Kubota. The company is considering other options in case negotiations do not work out, he said.
“My concern is taking care of our employees and making sure our employees and their family members have health care coverage in an in-network situation,” Sutton said.
Hall County Schools also provides Anthem to its employees, and Superintendent Will Schofield said he would like to see an agreement reached.
“Many of our 3,400 employees depend upon NGHS for at least part of their family medical care,” Schofield said. “It would certainly be my hope that Anthem and our local folks would come together and quickly move towards a fair and equitable solution.”
Fieldale Farms has been with Anthem for 40 years. President Tom Hensley said he wants the company to be able to stay with Anthem.
Hensley said he also has concerns about employees having to travel farther for care if NGHS and Anthem can’t reach an agreement. He said he had had positive experiences with NGHS — “they’re great people, great doctors and a great facility, and if I ever get sick, that’s where I’m going to go” — but he does not believe the health system has been flexible in its negotiations.
“They’re going to cost Fieldale a couple million dollars a year for the same service we’ve been getting, and I just don’t feel that they deserve that or need it,” Hensley said.
Hensley said as of now, Fieldale wants to stay with Anthem.
“We don’t change allegiance this easily,” he said.
Both NGHS and Anthem are promoting online resources to inform patients. NGHS has set up a website with information on the negotiation, and Anthem has a database with in-network providers so people can look at their options.
Patients can apply for continuity of care if they are pregnant or undergoing an active course of treatment. First, they should call the number on the back of their Anthem card, and then they should work with their physician.