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A dispute between Maine’s largest health care insurer and largest health care provider threatens to leave thousands of people without access to needed care. It also highlights the dysfunction of our health care industry and its finances.
Earlier this month, Maine Medical Center in Portland announced that it would essentially drop in-network coverage for patients with Anthem Blue Cross and Blue Shield insurance beginning in January. These patients may still be able to be treated at the hospital but they may need prior approval and would pay higher rates. Emergency room services for Anthem subscribers will still be covered.
Insurance companies and health care providers often negotiate rates and terms for services and treatments. It is unusual for the negotiations — and disagreements like these — to spill into public view, showcasing the discord between the two largest players in Maine’s health care system.
Discussions of patient care are largely lost in the debate.
MaineHealth, the parent company of Maine Medical Center, said that Anthem owes it more than $70 million for services over the last three years. Anthem has also been withholding payments totaling around $13 million a year, MaineHealth officials said. Other MaineHealth providers and offices will continue to accept Anthem insurance.
Anthem has faced similar complaints and disputes in several other states. Last month, the state of Georgia fined the company $5 million after officials there said Anthem misled patients about what hospitals and providers were available through its network.
Anthem has countered the Maine Medical Center claims by saying that the hospital is inflating prices, which raises insurance and health care costs for all patients. For example, the company told the Portland Press Herald that the hospital charged Anthem patients $136 for a bag of saline that should have cost $2, and overcharged for tissue used in breast reconstructive surgeries for cancer patients. The hospital said it needed more information to assess these claims.
Gov. Janet Mills has urged the hospital and Anthem to resolve the dispute. The governor’s sister is an executive at MaineHealth. Anthem provides insurance coverage to state employees.
This dispute comes as calls for more transparency around charges for hospital services and decisions about insurance coverage intensify. Under the Affordable Care Act, insurance companies must devote most of their premium charges to patient care, not administration, salaries and profit. The ACA, which has been codified into Maine law, also includes many procedures, such as mental health services, pregnancy care and preventative services, that must be covered by insurance.
Hospital billing, on the other hand, is not subject to similar government rules and lacks much transparency. New laws, and a new Office of Affordable Health Care, created last year by the Legislature, may help increase transparency. The office, which was created by legislation sponsored by Senate President Troy Jackson, is charged with reviewing the state’s health care system and developing proposals to “improve coordination, efficiency and quality of the health care system.”
In addition, the Legislature’s Health Coverage, Insurance and Financial Services Committee will soon hold a meeting with representatives from Maine Medical Center and Anthem to discuss this situation.
“These types of disputes and ongoing issues are why we need to continue the work to reform our health care system in Maine and across the country,” Jackson told the BDN editorial board. “The system is complicated from tricky insurance claims and difficult-to-read medical bills to the pricing of prescription drugs, all of which give industry players the cover to trade blame over outrageous prices while patients are left grappling with the cost of treatment and care.
“The Office of Affordable Health Care has a role to play to reform our system here in Maine in the long run,” the Senate president added. “However, in the meantime, the Legislature’s Health Coverage, Insurance and Financial Services will hold a hearing in the coming weeks to give both MaineHealth and Anthem a forum to present their side of the dispute. At the end of the day, the two parties must resolve the issue quickly for the sake of Maine people who are stuck in the crossfire.”
This dispute, and others that are likely to follow, lend support to the notion of a single payer healthc are system. Under such a system, one payer — often the government — would cover the cost of health care, typically for a large population. Medicare and Medicaid are single-payer systems. Both have much lower administrative costs than private insurance plans.
Health care funding — hospital billing and insurance claims payments — is complex and often confusing. Both lack needed transparency for patients.
We hope that Anthem and Maine Medical Center will reach an agreement before January so thousands of patients won’t have their medical care disrupted or delayed. But this standoff should prompt lawmakers to take a much harder look at making the entire health care system better, more transparent and centered on patients’ needs.