Allowing Insurers to Shape the Healthcare Ecosystem Hurts Patients

Third-party payers are a necessary part of healthcare, but when reimbursement models become so convoluted that they destabilize the entire ecosystem, we need to call for change.

Take, for example, the ongoing dispute between Excellus BlueCross BlueShield and WellNow Urgent Care in Central New York. Over the past ten years, Excellus has steadily raised premiums it charges for patients by 45%, while at the same time reducing what it pays WellNow for the care we provide to those patients by 35%. The result of this unworkable imbalance hurts patients the most, especially those living in healthcare deserts.

While the Excellus dispute is happening on a small scale, it serves as a case study illustrating how outmoded and unfair reimbursement models are hurting patients and providers alike. Throughout the country, insurance companies continue to charge patients higher premiums, yet reimbursements to caregivers have not kept up with inflation at best, and have significantly decreased at worst.

If we don’t address this problem now, the healthcare ecosystem will continue to destabilize until medical care is harder to both access and provide for everyone.

Different sites of care each play a necessary role in the healthcare ecosystem

Every part of the healthcare continuum has its role in the ecosystem. Primary care is ideally the backbone of healthcare; every patient should have a primary care physician to manage their continuity of care, from chronic conditions to episodic illnesses. On the other end of the spectrum, emergency departments exist to address catastrophic injury and illness at any time.

Primary care and emergency care would complement each other well if not for several inconvenient realities. For one, a national shortage of primary care physicians makes it difficult for patients to access primary care; in some areas WellNow serves, there are no primary care options available. Additionally, there is an entire generation of Americans that eschews primary care in favor of reasonably priced, as-needed episodic treatment through urgent care centers and retail clinics, which offer extended hours, convenient locations, and walk-in availability.

As for emergency departments, many are overwhelmed, resulting in long wait times that can exceed four hours in some localities. In terms of cost, receiving care from an emergency department can be ten or more times as expensive as receiving the same care from an urgent care center. That’s not to say that all patients seeking medical assistance should turn to urgent care; for those with emergent injuries and illnesses, emergency departments are still the best option. However, a large percentage of patient care needs can be met by urgent care clinics for a fraction of the cost, ultimately saving both patients and the healthcare system billions of dollars annually.

For these reasons, urgent care fills a vital role in the healthcare continuum, bridging the gap between primary care and emergency departments, and filling the void for those for whom primary care options are limited or, in many cases, unavailable. Urgent care clinics can provide the convenience of immediate access to necessary services, including imaging and lab testing, along with more reasonable costs.

Reimbursement models are not reflective of the value different healthcare sites provide

Urgent care centers fill a different need compared to primary and emergency care, but payment models don’t always reflect this distinction, to the detriment of patients and providers alike. 

In the case of Excellus and WellNow, the issue of proper reimbursement has come to a head. In certain parts of New York State, Excellus, operating as Univera, has a lower market share among patients. In those areas, WellNow is paid properly, as an urgent care provider. In contrast, just a few miles away in Central New York where Excellus is dominant, they pay WellNow at significantly lower primary care rates.

Why does this matter? Primary care reimbursement models involve higher payments for new patient visits, because providers require more time. But after the new patient visit, primary care providers are paid less for subsequent patient visits, because they require less time. However, at an urgent care clinic, providers may see the same patient for an ankle sprain one month and pneumonia the next. These types of visits are drastically different from ‘established’ patient visits, each requiring a significant amount of time and care, and are therefore more akin to new patient visits than established patient visits. When payers try to reimburse urgent care centers at lower primary care rates for established patients, the result is higher copays for patients and improper payment to providers.

This dance between payers and providers should not occur. It’s not fair, and it doesn’t make sense. As providers, we’re here because we want to take care of patients. Disputes like what is happening between Excellus and WellNow, and other payers and providers across the country, muddies the waters. We have to make sure we are paid appropriately, or else we risk losing the ability to continue caring for patients.

Improper reimbursement hurts patients

What happens when providers aren’t paid appropriately? It’s simple: access to care is reduced for patients in need. In New York, WellNow has had to temporarily close several locations and condense our staff, which doesn’t serve patients or communities well.

When patients cannot access care from an urgent care center in their community, they have three options, all of which present obstacles. Patients can try to see their primary care physician, assuming they have one. As previously mentioned, there is a national shortage of primary care physicians; most are booked solid and they don’t see walk-in patients. If they can’t access primary care, patients can go to the nearest emergency department, but that could mean long wait times and exorbitant costs. Finally, patients can delay care, which can have devastating outcomes.

The lack of proper reimbursement is a simple problem with complicated consequences. Without proper payment, medical facilities cannot recruit and retain staff. Without staff, healthcare options begin to evaporate, especially in underserved communities. Without options, patients are forced to make difficult choices that only result in further costs, both to the patient as an individual and to the healthcare system at large.

If this situation is allowed to continue, the ability to access timely healthcare economically will continue to diminish across the country.

Stop letting insurers shape the healthcare ecosystem

We became providers because we genuinely care about helping patients. For too long, we’ve let others determine the shape of the healthcare landscape–but that framework is no longer workable. Personally, I’ve loved my career as a board-certified emergency medicine physician, and I cannot sit and wait for someone else to ensure that my fellow caregivers are paid the way we should be.

It’s easy to feel like one person’s voice can’t make a difference, but it absolutely can. In addition to providers, hospital administrators and other healthcare professionals can effect change by talking to providers and involving them in business decisions. For providers, administrators, and patients alike, advocating for proper reimbursement models by contacting elected officials is paramount. In the case of Excellus and WellNow, we’ve established a website to help providers and patients make their voices heard.

The way Excellus is treating WellNow may seem small-scale, but this issue is cropping up on a much larger scale, too. Just recently, six Mount Sinai hospitals went out-of-network with UnitedHealthcare due to a similar payment dispute, and this situation is hardly unique.

We cannot allow insurers to impair patient care and the performance of the healthcare ecosystem through decisions driven by their short-term profit alone. Without proper reimbursement models, patients will increasingly be unable to access the care they need at a reasonable cost; providers will continue to be paid unfairly; and potential caregivers will be wary of entering the profession at all. Without intervention, this problem will become a massive issue that will dramatically affect patients’ lives. 

It’s time to make our voices heard.