Much has been said and written about the conflict between MaineHealth and Anthem, both large players in Maine’s health care landscape with deep pockets and much at stake. However, the impact of reimbursement from insurance carriers goes well beyond Maine’s largest hospital and the largest insurance company. It adversely affects every ambulance service, which is a classic example of a small-business model trying to survive and provide an essential service.
Like hospitals, emergency medical service providers are also struggling to be paid appropriately by Anthem and other insurance carriers. To put this in perspective, the cost of operating one ambulance 24/7/365 is nearly $1 million annually, and, in the best of circumstances, insurance reimbursement covers only about 80 percent of the cost.
The reason for this is that ambulance services must be staffed, equipped, trained and ready to respond all the time and everywhere – and when called upon, they are required to respond, treat and transport if medically necessary, regardless of a patient’s insurance status or ability to pay. Insurance pays only when patients are transported to a hospital or other approved destination. If the patient refuses transport or is treated and released, the ambulance service receives no income for responding to the scene.
While the current news is focused on a large private insurance carrier, primary reimbursement in a rural and aging state like ours comes from government sources: Medicare and MaineCare (Medicaid). The time and effort it can take to receive payment from both government and private insurance companies are excessive for small businesses that are just trying to keep the lights on and the wheels turning, and are increasingly painful for patients as well. Unfortunately, for Maine Medical Center and many other providers, it has taken the drastic step of termination to bring awareness to the public and force insurance companies to the negotiating table.
The nature of EMS makes this untenable situation a true public health crisis that threatens the health and safety of every Mainer. While it seems inconceivable to think that a call to 911 may go unanswered, such a nightmare scenario is frighteningly closer on a daily basis than the public may realize. So, what’s being done about it? And what more can be done?
To help struggling ambulance services, in 2020 the Maine Legislature passed LD 2105, legislation that required the Board of Maine EMS to work with the major insurance carriers and the Maine Ambulance Association to develop recommendations to get more ambulance services “in network” and more adequately reimbursed by commercial insurance plans.
The unanimous recommendations of this work group were to adjust MaineCare rates to fully align with Medicare and to make contracting with private carriers more streamlined, including a contract “standard offer.” The recommendations resulted in legislation that passed with strong bipartisan support and went into effect Oct. 1, 2021. The MaineCare changes went into effect April 1, but the private carrier “standard offer” continues to be widely ignored or creatively interpreted by the same private carriers that, a year earlier, had raised their hands in support.
Our relationships with insurance carriers are important for the survival of our business and their subscribers. But ambulance businesses are scattered all over the state, and our voices get dwarfed by the concerns of the large health care systems and ignored by private carriers. The fact is that EMS providers cannot continue to undercut themselves.
As a state, we must compensate EMS providers commensurate with the great responsibility we place on them. We must ensure they have the resources, equipment and personnel to answer every call. We must also call out insurance companies that refuse to acknowledge their role in our failing system. We need proper funding – and we needed it yesterday.