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Denise McDonough is the president of Anthem Blue Cross and Blue Shield in Maine.
All of us at Anthem Blue Cross and Blue Shield in Maine are deeply committed to providing our 300,000 members access to high-quality, outcomes-driven health care. We believe MaineHealth shares these goals. where our two perspectives divergehowever, is that our work centers on ensuring that care is affordable.
The reality is, health care costs in Maine are high — some of the highest in the country — and if we are not vigilant, they’ll continue to climb higher. an objective 2019 study by the University of Pennsylvania ranked Maine as having the fourth-highest health care cost burden for working families in America, and a 2020 study by the RAND Corp. showed prices paid to hospitals in Maine by private insurers are 252 percent of what Medicare would have paid for the same services at the same facilities.
The result? Maine can be such an expensive state for health care that some employers find it more cost-effective to send their employees to Boston for certain surgeries or care.
The findings of these studies and others do not come as a surprise to me, nor to Maine employers and consumers. The majority of our members in Maine work for companies that are self-funded, which means an insurer like Anthem administers the plan, but the employer pays for health care costs directly; any increases health systems charge for medical expenses is a direct increase in the expenses they pay. Employers with “traditional” plans, where the insurer assumes the risks and the costs, see their premiums increase as costs go up.
Simply put, the prices health systems charge for services are the primary driver of health care spending. If the cost of services continues to rise unchecked, all Mainers will pay more for health care through higher premiums and higher out-of-pocket costs. If that sounds unsustainable, that’s because it is.
At Anthem, our role is to protect our customers from increased costs and to protect affordability for the businesses and people we serve. That’s the whole reason why we enter into contractual relationships with providers and health systems: to be stewards of our customers’ money.
Our work is as important now as ever. Through routine audits, we discovered MaineHealth has overcharged our members. In 2018, we discovered overbilling by Maine Medical Center in Portland for anesthesia and operating room services. As a result of an investigation, MaineHealth eventually acknowledged the overcharging and issued refunds amounting to nearly $20 million. If it were not for our internal audits — a system of checks and balances to protect our members — these overcharges may never have been discovered.
Unfortunately, we find ourselves in a similar situation, where through a routine audit, it was discovered that MaineHealth has once again overcharged Maine consumers and charged them for services they shouldn’t have, which we believe totals millions of dollars. Disputing such charges is at the heart of the current dispute with MaineHealth.
Anthem has been partners with MaineHealth for decades, and in order for all Mainers to have access to high quality, outcomes-driven health care, we strongly believe that this partnership must continue. To help resolve these matters with MaineHealth, we have engaged an independent mediator.
As the largest payer and provider in the state, Anthem and Maine Health have to responsibility to address the challenges of rising health care costs on behalf of the people we mutually serve. We at Anthem Blue Cross and Blue Shield agree with the governor that it is in the best interests of consumers to come back to the negotiating table and hash out our differences. I am committed to doing so, as are the hundreds of Mainers I work with every day. We are hopeful MaineHealth will join us.