By Jane Anderson
Insurers, led by
UnitedHealth Group and Anthem, Inc., are clamping down on sites of care for
services such as outpatient surgery, imaging, infusions and colonoscopies in an
effort to cut costs by utilizing cheaper free-standing facilities instead of
hospital-based outpatient departments.
UnitedHealth CEO Dirk McMahon said during a recent earnings conference call that United sees "considerable excess spending" on care delivered at "sub-optimal high cost settings." On United's commercial side, McMahon said, the insurer sees an opportunity to shift more than 20% of medical spend to what it terms "more effective sites."
Anthem, meanwhile, continues to enforce a controversial policy first implemented in 2017 to deny coverage for some emergency room visits it considers "non-emergency," and also has restricted coverage on hospital-based outpatient imaging.
UnitedHealth and Anthem are far from alone, says Timothy Epple, a principal at Avalere Health. "I think it's safe to say just about every insurer we've spoken to or work with is addressing site of care optimization and steerage in some way," he tells AIS Health.
Ashraf Shehata, a principal in KPMG's health care life sciences advisory practice, says these types of limits — with plans steering care to less-expensive settings — could still gain significant traction in certain markets. "I think in major metro markets we could see it shift a lot of care," Shehata says. "We could see the plan making it very attractive to compete on unit costs."
As this trend takes hold, hospitals might consider rolling up competition by buying ambulatory surgery centers and associated physician practices, Shehata says.
From
Health Plan Weekly
UnitedHealth CEO Dirk McMahon said during a recent earnings conference call that United sees "considerable excess spending" on care delivered at "sub-optimal high cost settings." On United's commercial side, McMahon said, the insurer sees an opportunity to shift more than 20% of medical spend to what it terms "more effective sites."
Anthem, meanwhile, continues to enforce a controversial policy first implemented in 2017 to deny coverage for some emergency room visits it considers "non-emergency," and also has restricted coverage on hospital-based outpatient imaging.
UnitedHealth and Anthem are far from alone, says Timothy Epple, a principal at Avalere Health. "I think it's safe to say just about every insurer we've spoken to or work with is addressing site of care optimization and steerage in some way," he tells AIS Health.
Ashraf Shehata, a principal in KPMG's health care life sciences advisory practice, says these types of limits — with plans steering care to less-expensive settings — could still gain significant traction in certain markets. "I think in major metro markets we could see it shift a lot of care," Shehata says. "We could see the plan making it very attractive to compete on unit costs."
As this trend takes hold, hospitals might consider rolling up competition by buying ambulatory surgery centers and associated physician practices, Shehata says.
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