By Alyssa Tolman
Wyoming Tribune Eagle
Via- Wyoming News Exchange

 

CHEYENNE — With costs rising nationwide, many patients, medical providers, insurers and others responsible for covering the cost of health care are scrambling to find ways to combat the challenges they are facing.

On Friday, the Greater Cheyenne Chamber of Commerce held its monthly luncheon, during which Blue Cross Blue Shield health care professionals Diane Gore and Rebecca D’Amico discussed changes introduced by the One Big Beautiful Bill and what they mean for the future of health care across the nation and in Wyoming.

 

The changes and challenges

D’Amico, chief of staff and vice president of strategy for the BCBS Association, said one of the more recent changes when it comes to health care is the No Surprises Act, which took effect in 2022.  It protects people from getting unexpected bills or higher costs than anticipated.

D’Amico said while this is a positive change, the downside is that some people take advantage of the policy, which can drive up the cost of health care.

“We’ve seen millions of disputes come through to be settled across payors and providers,” D’Amico said, “and it has added $5 billion worth of costs just in the past year, and $5 billion of costs just elevates cost for all of us that shows up in our premium.”

Another change the two discussed is coding intensity, which is a measure of how many and how complex the diagnostic codes are that a health care provider assigns to a patient’s record. Generally, the more complex the code, the more the medical provider is paid.

D’Amico said BCBS officials have been able to look into BCBS data, and have seen a significant increase in coding for medical conditions, which means higher reimbursement.

“You could all ask me, ‘Well, couldn’t that mean that people are getting sicker? Couldn’t that mean that people are seeking more care?’ Because we do see that, too,” D’Amico said. “Unfortunately, what we’re seeing, though, is that there’s not a rise in treatment for those conditions.”

Another challenge many will be facing soon is the expiration of Affordable Care Act enhanced subsidies at the end of this year.

D’Amico said the ACA allows people to be eligible for income-based subsidies, which is a sum of money granted by the government to assist an industry or business so that the price of a commodity or service may remain low or competitive. These subsidies — in the form of tax credits — partially cover premium costs on insurance purchased through the ACA Marketplace on healthcare.gov.

The American Rescue Plan Act and the Inflation Reduction Act, passed into law during the COVID-19 pandemic, increased the ACA subsidies temporarily from 2021 through 2025. Democrats in Congress have allowed the federal government to shut down and refused to vote to reopen it until Republicans negotiate and pass an extension of these enhanced subsidies.

Around 22 million of the 24 million Americans who get their health insurance through the ACA Marketplace receive some form of subsidy to lower their monthly premium. Once the enhanced subsidies expire, D’Amico said she predicts around 5 million people across the country will lose their insurance because they will no longer be able to afford the higher premiums.

This would also cause those who are still paying for coverage to see premium costs rise to double or more than what they are currently paying, D’Amico said.

Gore, BCBS of Wyoming CEO, said when these enhanced tax credits were passed in 2021, Wyoming saw participation in the individual marketplace almost double. She said in 2021, there were around 23,000 people enrolled, and today there’s roughly 45,000.

“Those tax credits help people be able to obtain access to coverage, which is what we want,” Gore said. “And in Wyoming, 96% of the people purchasing an individual policy do receive a subsidy, and it covers roughly 83% of the premium dollar. … If these tax credits do indeed expire, as is current law, at the end of the year, we’re concerned we could see roughly 10,000 to 15,000 people in Wyoming choose not to renew their coverage.”

 

Risks of going without insurance

Gore said while BCBS of Wyoming is consistently working with national partners and state legislators on keeping insurance prices low, there may be some people who still struggle to afford it.

When this is the case, Gore said she’s aware those people will have to consider making the tough decision to go without insurance.

However, without insurance, Gore said costs for different health care-related services in Wyoming will skyrocket, so she encouraged everyone to keep this in mind when looking into premium renewals.

“(Surgery for) a fractured rib (would cost) $160,000,” Gore said. “An emergency appendectomy, $31,000. And certainly having medical debt isn’t the situation that we want anybody to find themselves in.”

 

BCBS Association advocacy

One of the top priorities the BCBS Association is advocating for, D’Amico said, is site neutrality.

In simple terms, site neutrality means that if a patient is getting a service — whether it’s in a hospital outpatient department, an ambulatory surgical setting or a doctor’s office — and it’s the same service at the same quality, it should cost the same.

“That might seem really simple, (but) that’s actually not how health care works, unfortunately,” D’Amico said. “So, one of our big priorities is really advocating for this concept of site neutrality, where we’re not paying (more) because somebody is sitting in a setting that might be attached to a higher- cost facility.”

 

BCBS of Wyoming advocacy 

When it comes to coding intensity, Gore said this is an issue she’s seeing in Wyoming, too.

Gore said BCBS of Wyoming has a payment integrity area in their system that allows officials to look at some of the “egregious” coding patterns among certain providers and flag those for free review before BCBS of Wyoming pays the claim.

“We try to be a reliable partner,” Gore said. “We absolutely desire to pay our providers a fair price for the services that they are performing, because that’s important in order for the reimbursement to be sustainable, and the health care ecosystem to be sustainable.”

Gore said BCBS of Wyoming also enters into active contract negotiations every year or every few years with various providers and hospitals to help keep health care costs down, and shops at specialty pharmacies to find the lowest net cost for any pharmaceutical item a member needs.

“The other thing that I think is important … is just investment in our communities,” Gore said, “because there are a lot of what we call social determinants of health out there. So we also partner very closely with our first lady’s Wyoming Hunger Initiative … because an individual can’t lead a healthy life without having access to healthy food.”

As state and national policies continue to shift, the health care officials both said they will continue to work hard to ensure Wyoming residents maintain access to essential health care coverage and resources.

“It’s not as much about paying medical bills,” Gore said. “It’s about helping people build healthier lives.”