Tens of thousands of Coloradans — including thousands in Summit County — could be forced to switch doctors or pay out-of-network charges if negotiations between two major health care entities don’t reach an agreement by May 1.

Contract negotiations between Anthem Blue Cross Blue Shield, the country’s second largest health insurance company, and CommonSpirit Health, the country’s third-largest hospital system, are coming down to the wire.

The existing contract between the two will expire at the end of the month, and if a new deal is not reached by then, CommonSpirit will no longer be in-network for Anthem members. About 35,000 Anthem members in Colorado — including about 2,000 in Summit County — have recently used a CommonSpirit hospital, according to the health insurance provider.

If no agreement is reached, CommonSpirit’s St. Anthony Summit Hospital, Breckenridge Emergency and Urgent Care Center, Copper Emergency and Urgent Care Center and Keystone Emergency and Urgent Care Center, as well as a dozen other facilities statewide, would no longer be in Anthem commercial and Medicare Advantage health plans. The Peak One Surgery Center in Frisco has a separate contract with Anthem and reportedly will remain in network for patients with Anthem insurance.

Both Anthem and CommonSpirit have released public statements warning of the potential changes. The two health care entities both say that negotiations are ongoing with the goal of reaching a resolution before the existing contract expires.

“This is a common tactic in rate negotiations, and we’ve experienced this before in Summit County,” Summit County Commissioner Tamara Pogue said in a statement. “Ultimately, both parties need to work it out because that’s what’s in the best interest of Summit County consumers.”

Dueling claims

CommonSpirit said in a statement shared with Summit Daily News that while it hopes to reach a new agreement with Anthem to avoid disruption to patients, Anthem is proposing reductions in reimbursements for care “at a time of record inflation.”

“We believe every patient deserves access to safe, affordable and high-quality health care from doctors and nurses of their choice,” CommonSpirit officials said in the statement. “Responsible agreements with insurance companies allow us to attract and retain health care professionals, bring new services to the community, invest in new technology and maintain our facilities.”

CommonSpirit has said publicly that multiple counter proposals have been made to Anthem throughout the negotiations. Anthem removing CommonSpirit’s Colorado hospitals, clinics, physicians and providers from its network could force Anthem customers, “to travel great distances to receive the care — especially specialized care — that patients are accustomed to,” CommonSpirit officials stated.

In statements, CommonSpirit points to its nonprofit status and claims that, if an agreement is not reached, its “ability to provide even the most essential care to all patients, especially underserved patients in low-income communities, will be threatened.”

Anthem, meanwhile, claims in public statements that CommonSpirit has informed the insurance company it will leave its health plans if Anthem does not agree to reimbursement rate increases more than three times the rate of inflation.

Anthem State Plan President Matt Pickett said in a phone interview that CommonSpirit is already one of the more expensive health systems in Colorado and said the reimbursement rate increase being asked for is “abnormal.”

If Anthem were to accept high reimbursement rates, the costs would be passed along to employers and members throughout the state, Pickett said.

“Any sort of cost increase like this, like three times the rate of inflation, has a direct impact on what employers are paying, and what the members who are covered under those plans are also paying,” Pickett said. “That’s why we’re going through this negotiation, is to keep things affordable for our members and employers.”

Anthem claims in public statements that emergency room rates at CommonSpirit mountain and rural facilities as well as CommonSpirit Front Range facilities are significantly higher than all other nearby systems.

Pickett said that he is “optimistic” that Anthem will reach an agreement with CommonSpirit before the looming deadline to avoid disruption to patients. But if a deal is not reached by May 1, those already receiving care at CommonSpirit will not immediately lose access and other options are available through Anthem, including Vail Health facilities in Summit County, he said.

Anthem members who have questions or concerns should call the number on the back of their insurance cards, Pickett said.

“We want to make the point: Members who are going through some course of treatment today or perhaps are pregnant, they will continue to be able to see their CommonSpirit provider for a period of time,” Pickett said. “Our team members are reaching out to those members with serious or complex conditions to continue their care.”

Patients ‘caught in the middle’

Blue River resident Alexander Kestly is among those who does not know whether he will have in-network access to his doctor at CommonSpirit’s St. Anthony Summit Hospital as soon as next month. 

Kestly said the whole reason he and his wife chose an Anthem health insurance plan through the Colorado health care exchange is because Anthem provided in-network access to CommonSpirit. 

If a deal is not reached, he said he worries that he and his wife may have to travel to the Front Range to get basic treatment.

“It doesn’t seem like either party is negotiating in good faith, and the patients just get caught in the middle,” Kestly said. “If you really cared about the community and you really cared about people’s health, why are you doing this now?”

Adam Fox, the deputy director of the Colorado Consumer Health Initiative noted that because of the size of the two health care entities embroiled in these negotiations, there is a lot at stake. For some state residents seeking health care on the individual market, Anthem is the only available option, and CommonSpirit hospitals are “fundamental” to the health care landscape in some regions of the state, Fox said.

Despite the potential statewide impacts of negotiations such as these, Fox said it can be hard for the public to parse the claims being made by either entity — even as consumers become bargaining chips in the dispute.

“So much of these kinds of contract negotiations really happen behind closed doors and are never really disclosed publicly,” Fox said. “That gives both of these entities a lot of leeway in what they say, essentially, and there’s not really a good way for the public to understand or verify what is actually accurate.”

But Fox did note that publicly available data shows that CommonSpirit already has some of the highest reimbursement rates in the state. According to the Center for Improving Value in Health Care, St. Anthony Summit Hospital had the highest outpatient reimbursement rates in the state from 2017-2018, the most recent data available.

Commercial insurers at St. Anthony Summit Hospital paid 641% of what Medicare would pay for the same outpatient services, the public data shows. Commercial insurers also paid 417% of what Medicare would pay for the same outpatient services at CommonSpirit’s Mercy Regional Medical Center in Durango and 446% of Medicare at St. Anthony North Hospital in Westminster.

Those reimbursement rates are above the state average of 312% of Medicare and national average of 267% of Medicare for outpatient service payments.

Fox also noted that a Colorado Division of Insurance financial analysis of CommonSpirit in 2023 found that St. Anthony Summit Hospital “is cost efficient and very profitable as compared to 23 other U.S. hospitals with similar characteristics.”

In fact, St. Anthony Summit Hospital reported profit margins of 35% or more in 2020 and 2021, “which means more than one-third of Summit’s total revenue is profit,” according to the Division of Insurance report.

“I think that it raises some real questions about what CommonSpirit is really doing,” Fox said about the publicly available data. “As a supposed nonprofit entity that is supposed to be providing community benefit, I think there are some serious questions.”

Both Anthem and CommonSpirit are “trying to generate fear” by using the health care options available to consumers as leverage in the negotiations, Fox said. Oftentimes, negotiations like this between health care entities resolve smoothly when an agreement is reached, he said, but that isn’t always the case.

“Unfortunately, what I think we’re seeing is these large health care entities essentially trying to use patients as leverage to advance their position, whether that’s for more money or, in the case of the insurer, to secure lower reimbursement rates,” Fox said. “They’re essentially putting fear into patients about losing access to care to strengthen their negotiating position. From our perspective, that’s not acceptable to put patients in the middle like that.”