Stress has caused Amber Shipman to lose sleep and shed tears as her family deals with the fallout of an ongoing contractual dispute between Springfield Clinic and Blue Cross and Blue Shield of Illinois.
The clinic became an out-of-network provider for Blue Cross members in mid-November – a change that affected up to 100,000 central Illinois residents and was the biggest disruption of coverage in the Springfield area in decades.
Based on comments from both sides, there’s no end in sight to the situation.
The resulting higher out-of-pocket costs for Blue Cross members with longtime clinic doctors have prompted Shipman, 41, to put off routine medical care as she delayed switching to a new primary care doctor and a new OB/GYN specialist.
Her family has incurred thousands of dollars in additional health care costs, and one of her two sons, a leukemia survivor, will have to wait months longer to go outside Springfield Clinic and see a dermatologist at Southern Illinois University School of Medicine to evaluate his higher-than-normal risk of skin cancer.
She said she is angry that her family has become collateral damage in the local version of struggles playing out nationwide between medical groups and insurance companies over health care costs.
“I blame both of them,” Shipman said, referring to the clinic, one of Illinois’ largest for-profit group practices of doctors, and Chicago-based Blue Cross, the state’s largest insurer.
“It’s just about the money for them,” she said. “How much money do you need? I can’t pay my bills.”
Shipman and her family are among thousands of Springfield-area residents who have left or are considering leaving their care providers after the clinic and Blue Cross were unable in 2021 to work out a preferred-provider agreement that kept the clinic in-network.
The dispute is the type that goes on often across the country as medical providers try to preserve or increase reimbursement rates for care and insurers try to hold the line on costs.
But the process, which normally happens in private, went public last year as both sides explained their actions to patients in letters, emails and website posts, and the allegations were covered by the news media.
Springfield Clinic officials contended that Chicago-based Blue Cross was part of a parent organization that earned record profits during the COVID-19 pandemic, and the deal Blue Cross wanted would have harmed the clinic’s ability to attract and retain doctors to central Illinois.
The two sides described the impact of the ongoing dispute differently.
Springfield Clinic officials previously said Blue Cross members represented more than 100,000 people, or about 20% of the clinic’s patients.
Clinic spokesman Zach Kerker wouldn’t say how the change to out-of-network status has affected the clinic’s revenues. He also wouldn’t respond to Blue Cross spokeswoman Colleen Miller’s statement that the insurer has data showing an almost 93% drop in members using the clinic after the clinic became an out-of-network provider on Nov. 17, 2021.
But Kerker, in a written statement, said, “The reality is there aren’t enough in-network options in this area, and BCBCIL’s decision to terminate Springfield Clinic from the PPO plan has forced countless people to forgo or delay care.”
Miller said in an email that Kerker’s statement is “baseless.”
“Our claims data clearly indicates that our members are finding and using in-network providers to meet their health care needs: Two other provider groups in the area saw a more than 60% increase in the number of BCBSIL members in December 2021 compared to December 2020,” she said.
Dr. Jerry Kruse, dean and provost of SIU School of Medicine, said the SIU Medicine medical group is seeing 30% more Blue Cross members than a year ago, and SIU providers overall have been able to accommodate the influx without an increase in wait times for an appointment.
Even with the Blue Cross network’s loss of the clinic’s more than 600 doctors and other providers in 80 different medical specialties, Miller said Blue Cross offers in-network access to more than 3,000 providers across Sangamon, Christian, Logan, Macon and Morgan counties.
She said Blue Cross estimates about 55,000 of its members were affected when the clinic became an out-of-network provider – fewer than the 100,000 members estimated by the clinic.
Miller said members still can ask Blue Cross to continue seeing a clinic provider on an in-network basis for treatment of a “life-threatening condition, serious acute condition or (those who) are in the third trimester of pregnancy.”
Blue Cross officials have said the premiums central Illinois workers and employers pay are 16% higher than in the Chicago area.
Miller said Springfield Clinic “hasn’t yet indicated a willingness to discuss an agreement that focuses on improved health outcomes and more affordable care, but we’re always open to resuming those discussions.”
But Kerker said, “Any suggestion that Springfield Clinic has not negotiated in good faith is untrue. We made a proposal in August, but based on BCBSIL’s communication to us, we do not anticipate an agreement.”
Some employer groups have said they switched insurance carriers to make sure their workers had in-network access to the clinic, while others have stuck with Blue Cross, according to Andrew Novaria, an employee benefits consultant and insurance broker with American Central Insurance Services.
The next major date for employers to renew or change insurance plans is July 1, he said.
Some patients likely are biding their time and delaying care in hopes that the two sides will work out a deal, he said.
Springfield-based Mel-O-Cream Donuts International stuck with Blue Cross even though many Mel-O-Cream workers lost in-network access to their clinic doctors, and the doughnut maker is unhappy that the health insurance it is offering has less value for workers, according to Chad Larson, vice president of manufacturing.
Mel-O-Cream may decide in April to leave Blue Cross if the dispute still isn’t resolved, he said.
The Shipman family gets its Blue Cross PPO insurance through Mike Shipman’s job as an AT&T marketing support specialist, and there wasn’t another insurance option that the family could switch to with coverage for everyone’s doctors at a variety of medical groups. As a result, the family’s access to Springfield Clinic doctors depends on whether the clinic and Blue Cross can resolve their differences.
Amber Shipman said she delayed leaving her Springfield Clinic doctors for several months because she was “trying to be optimistic” about a deal. Now she is waiting to hear back from SIU about doctors accepting new patients.
Shipman, a call center worker for Ascend marijuana dispensaries, said she feels bad that she can’t afford the higher co-pays for her son, Aaron, 18, to see a dermatologist from the clinic.
Her husband, Mike, 46, has continued to see his primary care doctor at the clinic – incurring out-of-network charges – to prepare for his back surgery, now scheduled this week with an Orthopedic Center of Illinois surgeon.
But Amber Shipman said it took two ER visits for her husband complaining about back problems before he could get a quick referral to a surgeon, rather than wait weeks to see an SIU surgeon.
Mike Shipman said the hassle related to the squabble between Blue Cross and the clinic “completely stresses me out. … Neither company is hurting. They need to meet in the middle and start working for their patients.”
Dean Olsen is a senior staff writer for Illinois Times. He can be reached at dolsen@illinoistimes.com or 217-679-7810.
This article appears in Meet us at Southtown.
