Anthem said it will stop paying for MRIs and CT scans performed on an outpatient basis at hospitals.
The large payer is making the change in an effort to push patients to less expensive freestanding imaging centers. Hospital executives are concerned the policy change could hurt hospitals’ bottom lines and patient access to care.
Anthem will implement the policy in 13 of its 14 states by March 2018. Only New Hampshire will not have the new policy, which is already in place in Indiana, Kentucky, Missouri and Wisconsin and will start in Colorado, Georgia, Nevada, New York and Ohio next month.
Hospitals are continuing to increase the outpatient care they perform for a number of reasons. Patients often find it more convenient, and payment rates are usually higher than for services performed at a physician's office. Imaging done at a stand alone clinic can be drastically cheaper, and Anthem is looking to cut costs its deems unnecessary.
The largest payer in the country is as well. The CMS has a proposal to make costs more site neutral by paying services at off-campus hospital outpatient departments at 25% of regular outpatients rates. The same proposal also includes a small increase (1.75%) for outpatient payments. The American Hospitals Association generally opposes site-neutral regulations, arguing the change could reduce patient access to care. But other healthcare organizations, including the American Medical Association, say it levels the playing field and helps smaller practices stay afloat.
Such government regulations can embolden private payers looking to make smaller payout adjustments. Anthem has not been shy about its intention to home in on reducing unnecessary care by restricting payments, and therefore reducing the chance of a perverse incentive. Doctors and payers don't always agree on what care is deemed necessary, however.
The major payer of Blue Cross plans also recently announced it would no longer cover emergency department (ED) visits that it deems unnecessary in Missouri. In that case, Anthem said a company medical director will review the ED claims information and decide whether symptoms and diagnoses warranted an emergency visit. Anthem has the same policy in Kentucky and Georgia and may expand to more states. Anthem said the Kentucky policy has been in place since 2015 and has only denied a small percentage of ED claims.
Hospitals and patient advocates don't like the policy at all. Missouri healthcare executives sent a letter to the state's insurance director requesting a review of the new ED policy. The executives said the policy is “unfair to policyholders, and downright dangerous for patients.”
Both of Anthem’s recent policy changes deal with trying to limit services in hospitals. The payer would prefer that patients instead visit less costly facilities, such as freestanding imaging centers and urgent care centers, whenever possible.
Hospitals are stuck in a difficult financial situation. Lower inpatient admissions means they need to find money elsewhere, so many have expanded outpatient services such as imaging. Through these types of outpatient services, hospital executives are finding a way to maintain positive balance sheets. However, Anthem’s decision will result in Anthem members getting their MRIs and CT scans from outside of hospitals. This will squeeze hospitals further and result in a win for freestanding imaging centers.
Anthem is a major payer, and competitors will be watching to see how this new policy affects Anthem. If other payers follow suit, hospitals across the country may need to find other ways to get or stay in the black.