The rising importance of choice

Many people have experienced it: an unexpected illness or injury disrupts the day, or routine bloodwork gets pushed further down the to-do list. 

Today, people have more choices than ever for receiving non-emergency care, from virtual care and urgent care to retail clinics and ambulatory surgery centers. But where people receive care can significantly affect both costs and the overall experience.

For routine or non-emergency care — such as diagnostic imaging, lab work, infusions and procedures that don’t require an overnight hospital stay — people typically have two categories of choice:

• Hospital-based outpatient settings, where people receive care without being admitted overnight; and
• Non-hospital settings such as your primary care doctor, an ambulatory surgery center, urgent care clinic or virtual care.

For example, virtual care may be a convenient option for flu-like symptoms, allergies, rashes, or sinus infections, while urgent care may be more appropriate for sprains, ear pain, or minor injuries.

But different care settings come with different price tags. For example, research consistently shows that hospital outpatient departments typically receive higher reimbursement rates, and charge more due to facility fees, even when the quality of care is the same. A recent study found that infusion care received in hospital outpatient departments resulted in 42% higher costs than care provided in non-hospital settings, despite similar outcomes and patient experience. In many cases, people can receive the same high-quality care in lower-cost settings, without sacrificing outcomes or convenience.

The challenge is that these cost differences can be hard to anticipate. While the emergency room (ER) may seem like a good choice for unexpected care needs, it typically costs more and takes longer than other non-emergency care options.

That’s why helping people understand their options and identifying high-quality, lower-cost alternatives is a core focus for Anthem. Through care navigation tools and support, members in Maine can compare care locations, understand potential cost differences and explore lower-cost, high-quality alternatives when clinically appropriate. 

Why cost and care experience matter

When people default to higher-cost settings without understanding their options, the impact goes beyond cost alone. They may also encounter more complex, fragmented care experiences that feel harder to navigate, particularly for services that are non-urgent. Care settings outside the hospital may offer more convenient experiences, with options that can bring care closer to where people live. Plus, there are no hidden facility fees.

One non-hospital option that may be less known to people is ambulatory surgery centers. These centers can perform many of the same routine outpatient procedures as hospitals, such as colonoscopies or upper gastrointestinal (GI) procedures, but usually at a significantly lower cost. In fact, people can save thousands of dollars when these procedures are performed at an ambulatory surgery center (ASC). For example, a colonoscopy at a hospital outpatient facility can cost as much as $8,000 in Maine and as low as $2,000 when performed at an ASC. Where you go for care matters.

When people have access to this information earlier, they can make decisions that best serve their health needs and budget. 

How Anthem can help

For Anthem members in Maine, these tools and resources can help people find the right care, in the right place, at the right time, resulting in lower costs, fewer surprises and care that feels easier to navigate. For instance, with the Sydney Health app, members can compare costs, manage care in one place and get personalized information to help choose care that fits their needs and budget.

Knowing where to go for care is not always easy, but Anthem can help simplify the decision-making process. For many common health concerns, people may have options such as virtual care, urgent care, retail clinics or a doctor’s office that can save time, lower costs and reduce the stress of unexpected medical bills.

Learn more at anthem.com/healthcareinmaine.