Wednesday, December 11, 2013
Auburn resident Brenda Weeks uses a power wheelchair and has four to six doctor's appointments each month to manage her multiple sclerosis. Now a proposed health insurance deal may force the 54-year-old to switch physicians or buy a new policy.
In this September 2012 file photo, a patient is wheeled out of Barbara Bush Children's Hospital at Maine Medical Center in Portland. A state agency will soon decide whether letting Anthem and MaineHealth be Obamacare partners is a good idea.
Gregory Rec / Staff Photographer
Her doctors at Central Maine Medical Center in Lewiston would not be part of a health insurance network proposed by Anthem Blue Cross and Blue Shield, the state's largest health insurer, and MaineHealth, the state's largest network of hospitals and care providers.
A hearing will be held Friday by Maine's Bureau of Insurance on the proposed partnership between Anthem and MaineHealth. The pact includes 32 of the 38 hospitals in the state, but excludes the three hospitals owned by Central Maine HealthCare in Lewiston, along with Parkview Adventist in Brunswick, York Hospital in York and Mercy Hospital in Portland.
Some doctors are upset that they would be excluded from the plan, and some patients fear that they would no longer be able to go to the doctors and hospitals they now use. The proposal appears to run counter to President Obama's pledge that people will be able to keep their doctors and their health plans.
Anthem has sought permission to cancel the existing health insurance policies of individuals and small-group subscribers and replace them with new plans. That has not been approved by the Bureau of Insurance, and Anthem officials have said it is premature to comment on any changes.
The proposed Anthem-MaineHealth plan is one of two plans that will be sold through an insurance exchange under the federal Affordable Care Act. The other plan is proposed by Maine Community Health Options, a nonprofit, co-op insurance program. Both plans need to be reviewed by the Bureau of Insurance by July 31 and approved by federal regulators.
The health insurance exchanges in Maine will target the roughly 260,000 Mainers who have individual or small-group insurance plans and those who are uninsured. Enrollment is expected to begin in October. The plans would take effect Jan. 1.
Anthem approached MaineHealth last fall to create the network, said Colin McHugh, regional vice president of provider engagement and contracting for Anthem.
The plan, which is called a narrow or focused network that includes only certain hospitals, mirrors plans being created throughout the country in anticipation of the Affordable Care Act, said Trish Riley, senior fellow in health policy and politics at the University of Southern Maine's Muskie School of Public Service.
"It's a trend across the country for value-based purchasing to negotiate the best rates possible," Riley said. "It's a business arrangement. They are negotiating lower rates with hospitals that meet certain quality standards."
Anthem's goal was to create the biggest network practical throughout the state, and it still has "high regard for the hospitals that are not part of this plan," McHugh said.
"We created the broadest continuum of care across the broadest territory," he said. "Consumers may forgo access in the network in exchange for price considerations."
The network is still under review by the Bureau of Insurance, so details about pricing and numbers of patients have not been released.
Brenda Weeks said the Anthem-MaineHealth plan, which would require her to travel long distances in a handicapped-accessible van to visit new doctors in the network, appears to contradict Obama's promise that the Affordable Care Act would not require people to switch doctors. Weeks could have the same doctors if she bought coverage through the Maine Community Health Options network.
In an address to the American Medical Association in July 2009, Obama said: "No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away, no matter what."
The White House did not respond to the Portland Press Herald's calls Tuesday and Wednesday.
By controlling which hospitals are involved in the network, Anthem and MaineHealth can contain costs, the companies said.
The hospitals participating in the network agreed to accept reduced payments from Anthem in exchange for having more customers directed to their facilities, the companies said. For certain clinical services that aren't available in Maine but are offered in Boston, a consumer would still be covered under the plan.
The proposed plan "responded directly to some of our priorities of providing a less costly product for individuals and small businesses, and the opportunity to persuade more people that our hospitals and physicians are the right choice," said Francis McGinty, executive vice president and treasurer of MaineHealth.
Weeks said she has been a Blue Cross and Blue Shield subscriber for 29 years and doesn't want to change doctors or insurance plans.
"It would turn my world upside down," she said. "I've worked very hard building relationships with providers. It's not just as simple as going to the doctor and getting a Band-Aid. There's an awful lot involved in managing a chronic illness."
McGinty, with MaineHealth, said people will not be required to change doctors unless they buy the Anthem-MaineHealth product. If they want to keep their physicians and hospitals, they can buy the product being offered by Maine Community Health Options, he said.
"The only people who are going to be impacted are those who are buying this product because it is the right choice for them," McGinty said. "There are other choices available to them and we respect their decision."
Still, the possibility that they will have to change doctors or buy new insurance plans has upset some patients and providers.
"Most companies don't turn their back on their current customers. Sure, there are other options, but why should Anthem turn their back on their customers?" said Chuck Gill, a spokesman for Central Maine HealthCare.
Central Maine Healthcare, the parent of Central Maine Medical Center, and Bridgton and Rumford hospitals, slammed the Anthem-MaineHealth plan as a "backroom" deal that discriminates against consumers in central and western Maine. Central Maine Healthcare filed a lawsuit seeking the release of information filed by Anthem with the Bureau of Insurance. Some of that information was released by the bureau in the past week, such as the list of doctors and health care facilities in the proposed plan.
"We have been getting a peek at information here and there," Gill said this week. "But you play peek-a-boo when you're a child, not when you're dealing with people's health care. It's just three days before the hearing and we don't have all the information we need to respond."
Opponents also say the proposed Anthem-MaineHealth plan is more about shutting out competition than keeping down costs and maintaining quality of care.
For example, Central Maine Medical Center received the highest safety rating of four Maine hospitals examined by Consumer Reports in 2012, while MaineHealth's Maine Medical Center in Portland ranked fourth.
For 2013, Central Maine Medical Center and Maine Medical Center received "A" ratings from the LeapFrog Group, which measures hospital quality.
"It's not about high quality and low cost. Anthem and MaineHealth are basically not able to be believable about what they're saying," said Dr. John Kroger, a family practitioner in Rumford. "I can't take it seriously when they're saying this is about controlling costs and improving quality -- it doesn't meet any straight-face test."
Kroger said some patients from Bridgton to Rumford to Brunswick would have limited access and choice under the Anthem-MaineHealth plan. Kroger said he would lose dozens of patients, who would be forced to travel long distances to see doctors within the Anthem-MaineHealth plan.
"Hundreds of patients in the community will be affected," Kroger said.
Despite the claims that patients in central and western Maine would be left without access to care, some providers in the proposed Anthem-MaineHealth network are in central Maine, such as St. Mary's Regional Medical Center in Lewiston.
Having just two health plans on the exchanges in Maine is appropriate for a state with only 1.3 million people spread across a wide territory, said Riley, the senior fellow with the Muskie school.
"We have to think about what we had before. There were limited options before -- some with very limited coverage with high deductibles. The (Affordable Care Act) is an improvement in that it provides standard, good, comprehensive care. It provides subsidies for certain income levels," she said.
"Two networks is competition," said Riley, who was director of the Governor's Office of Health Policy and Finance under Gov. John Baldacci.
Each plan on the exchange will offer a variety of products, so there will be choices for consumers and small businesses.
"It's difficult to say there's only two plans when really there's multiple plans in each," Riley said.
Maine may not be the most attractive market to insurers because there's a small number of patients and more than three dozen hospitals to negotiate with, she said.
Central Maine HealthCare and MaineHealth have butted heads in the past over business developments.
In the late 1990s, Maine Medical Center objected to Central Maine Medical Center's efforts to start an emergency medical helicopter service. Not long after, Maine Med balked at Central Maine Medical Center's plan to build a cardiac center.
State regulators overrode those objections and Central Maine Medical Center proceeded with those efforts.
MaineHealth's McGinty said assertions about conflicts between Central Maine HealthCare and MaineHealth are "nonsensical."
"The fact that we decided to join with Anthem in creating this network has nothing to do with the fact that CMHC developed LifeFlight," an emergency helicopter service, he said.
Jessica Hall can be contacted at 791-6316 or at: