The Anthem-Maine Med Dispute Highlights the Complexity of Our Healthcare System

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A dispute between Maine’s largest health care insurer and the largest health care provider threatens to leave thousands of people without access to needed care. It also highlights the dysfunction of our healthcare industry and its finances.

Earlier this month, Maine Medical Center in Portland announced that it would essentially eliminate network coverage for patients with Anthem Blue Cross and Blue Shield insurance starting in January. These patients can still be treated in hospital, but they may need prior authorization and would pay higher rates. Emergency services for Anthem subscribers will still be covered.

Insurance companies and health care providers often negotiate rates and terms for services and treatments. It’s unusual for negotiations — and disagreements like these — to spill into public view, showcasing the discord between the two biggest players in Maine’s health care system.

Discussions about patient care are largely lost in the debate.

MaineHealth, the parent company of Maine Medical Center, said Anthem owed it more than $70 million for its services over the past three years. Anthem also withheld payments totaling about $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 hospitals and providers available through its network.

Anthem countered Maine Medical Center’s claims by saying the hospital was inflating prices, which increased 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 solution that should have cost $2, and overcharged tissues used in reconstructive breast surgeries for patients. suffering from cancer. The hospital said it needed more information to assess those claims.

Governor Janet Mills urged the hospital and Anthem to resolve the dispute. The Governor’s sister is an executive at MaineHealth. Anthem provides insurance coverage for state employees.

The dispute comes as calls for more transparency around hospital service charges and insurance coverage decisions intensify. Under the Affordable Care Act, insurance companies must spend the bulk of their premiums on patient care, not administration, salaries and profits. The ACA, which has been codified in Maine law, also includes many procedures, such as mental health services, pregnancy care, and preventive services, that must be covered by insurance.

Hospital billing, on the other hand, is not subject to similar government rules and lacks transparency. New laws and a new Office of Affordable Health Care, created last year by the Legislative Assembly, could help increase transparency. The office, which was created by legislation sponsored by Senate Speaker Troy Jackson, is tasked with reviewing the state’s health care system and developing proposals to “improve the coordination, efficiency and quality of the health system”.

Additionally, the Legislature’s Health Coverage, Insurance, and Financial Services Committee will soon meet 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 of reforming 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 hard-to-read medical bills to prescription drug pricing, all of which give industry players the cover to blame outrageous prices while patients are left to their own devices. taken with the cost of treatment and care. .

“The Office of Affordable Health Care has a role to play in reforming our system here in Maine for the long term,” the Senate Speaker added. “However, in the meantime, Legislative Health Coverage, Insurance and Financial Services will hold a hearing in the coming weeks to give MaineHealth and Anthem a forum to present their side of the dispute. Ultimately, both sides must resolve the issue quickly for the sake of the people of Maine who are caught in the crossfire. »

This dispute, and others that are likely to follow, support the notion of a single-payer health care system. In such a system, a payer—often the government—would cover the cost of health care, usually for a large population. Medicare and Medicaid are single-payer systems. Both have much lower administrative costs than private insurance plans.

Health care financing – hospital billing and insurance claim payments – is complex and often confusing. Both lack transparency for patients.

We hope that Anthem and Maine Medical Center will reach an agreement before January so that thousands of patients do not have their medical care interrupted or delayed. But this impasse should prompt lawmakers to take a closer look at making the entire healthcare system more transparent and centered on patient needs.

Sharon D. Cole