Independence Blue Cross, the Philadelphia region’s largest health insurer, launched this month a policy designed to move care into lower-cost surgery centers and away from hospitals and clinics that can generate payments twice as high for the same treatment.
The policy started June 1 echoes Medicare’s efforts to slow federal healthcare spending by paying the same price for outpatient procedures such as colonoscopies and knee surgery in hospitals as in surgery centers.
Pressure from employers to control costs has similarly motivated IBX and a newer regional competitor, Pittsburgh-based Highmark, which implemented a similar policy on Jan. 1. Both companies’ policies affect people with low risk of complications who are covered by commercial insurance or Medicare Advantage.
When doctors seek insurance authorization for certain procedures, IBX reviewers will ask whether doctors can treat low-risk patients in a surgery center, according to the company’s chief operating officer Richard Snyder.
“This is a gentle move,” Snyder said. “We’re not willing to force you to change doctors to have your colonoscopy or your service, but we want docs to get privileges in ambulatory surgery centers.”
The region doesn’t have enough low-cost surgery center capacity for a large-scale move to that setting, Snyder said. That means the policy might not hit hospital finances right away.
But the implication is that the policy could take a harder edge in the future. IBX’s goal is to spur the development of more surgery centers — either by the incumbent health systems or by new competitors, Snyder said.
Even now, the potential for delayed care and denied coverage has several regional health systems worried. Temple University Health System, for example, does not own ambulatory surgery centers, so the time could come when it has to coordinate care with outside providers.
The money at stake
Surgery to remove torn cartilage on the knee can cost $7,190 when performed on an outpatient basis in a hospital, nearly three times the $2,477 cost in ambulatory surgery centers, according to Philadelphia-area commercial insurance averages from heath prices data firm Turquoise Health.
Smaller gaps exist for hernia repairs and colonoscopies with a biopsy, Turquoise reported. Another data firm, Medscout, showed that a majority of those colonoscopies had already shifted to ambulatory surgery centers by 2024. The shift was far less advanced for hernia repairs — a procedure IBX is targeting.
Some physicians’ groups already are seeing opportunity in commercial and government insurers’ increased emphasis on surgery centers as a way to reduce spending — as well as regulatory changes that allow more procedures to be done in free-standing surgery centers.
Southeastern Pennsylvania now has four relatively new cardiovascular surgery centers.
Restore Orthopaedic Surgical Institute in Chadds Ford, founded by a group of Delaware doctors, has been quickly become a high-volume joint-replacement center.
In the coming year, Rothman Institute plans to open three surgery centers in the Philadelphia region, the private practice’s CEO Christian Ellison said.
Potential consumer impact
Several major health systems said the new site-of-care review policies raise questions about the potential impact on patients, without commenting on the implications for their finances.
Because Temple University Health System does not have any ambulatory surgery centers, “the policy will require certain studies and procedures to be referred outside the health system. This could create additional coordination requirements and may contribute to delays in testing, crucial diagnosis, and/or treatment,” Temple said in an email.
Main Line Health also said it anticipates the policy “could disrupt established care pathways, including in circumstances where surgeons lack privileges at available free-standing surgery centers,” the nonprofit said in a statement. Main Line has ownership interest in three surgery centers in Philadelphia’s western suburbs.
The University of Pennsylvania Health System said it will “advocate for our patients’ best interest and appeal any service denials based on the clinical and nonclinical exceptions outlined in the policy.”
Additional concerns for consumers include complexity, confusion, and possibly more risk of having care denied to what can already be a burdensome prior authorization process, said Christine Monahan, assistant research professor at Georgetown University’s Center on Health Insurance Reforms.
Monahan said she understands insurers’ impulse to steer people to lower-cost settings, but called policies like IBX’s “maybe not the most efficient way to handle the inefficient pricing in the system.”
The economic and political backdrop
The biggest increases in healthcare costs in 15 years are hitting employers this year, according to Mercer’s National Survey of Employer-Sponsored Health Plans.
The average increase was 6.7%, according to the February survey of 161 chief financial officers, who were not identified.
The increases are substantially higher than broader inflation. “It becomes more of a tax on employers,” Snyder said. “Next to salaries, many will tell you, that’s the biggest line item” in their expenses.
IBX has taken other steps to reduce healthcare spending, such as in 2015 introducing a benefit design that includes a preventive colonoscopy with no out-of-pocket costs for the patient at what are called Preventive Plus facilities. Elsewhere, they have a $750 co-pay.
Medicare has pushed for the last decade to pay the same for services in hospital outpatient departments as in doctors’ offices and surgery centers.
Medicare prohibited most new off-campus hospital clinics from billing at hospital rates in 2017. So-called site-neutral payments expanded in 2019 to include clinic visits. This year, the government applied the standard to payments for drug administration, such as chemotherapy.
Highmark Health Plans’ approach
In the first five months of under new policy, Highmark Health Plans has found some health systems are willing to accept lower surgery center rates for procedures performed within hospitals.
“What we’ve found is that a number have been willing to do that,” said Kate Musler, chief financial officer for Highmark’s insurance arm. “It may be advantageous for them to have that volume flow through the hospital and keep some volume there, it’s just not necessary in terms of the expense level.”
Musler cited bariatric surgery as an example of how technology and surgical practices have advanced to the point where a hospital is no longer needed.
It’s too early to say how much savings the new policy has generated, including in Southeastern Pennsylvania, Musler said. Highmark has seen its policy accepted at different levels across the five states where it took effect.
Some hospital systems are proactively shifting care to surgery centers to reduce costs, said Musler, who oversees Highmark underwriters helping employers understand their health expenses.
“We hear directly from employers who are making very difficult decisions,” she said. “It is now more than ever a question of whether they can afford employee health.”