anthem blue cross and blue shield - Maine.gov
anthem blue cross and blue shield - Maine.gov
anthem blue cross and blue shield - Maine.gov
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STATE OF MAINE<br />
DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION<br />
BUREAU OF INSURANCE<br />
IN RE:<br />
ANTHEM BLUE CROSS AND BLUE<br />
SHIELD REQUEST FOR APPROVAL<br />
OF ACCESS PLANS<br />
Docket No. INS-13-801<br />
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PREFILED TESTIMONY<br />
OF<br />
JUD KNOX<br />
Intervenor York Hospital submits the attached prefiled testimony of Jud Knox, President<br />
of York Hospital, <strong>and</strong> Exhibits A <strong>and</strong> B thereto.<br />
Respectfully submitted:<br />
Dated: June 27, 2013<br />
____________________________________<br />
Julius Ciembroniewicz, Esq.<br />
<strong>Maine</strong> Bar No. 8697<br />
KOZAK & GAYER, P.A.<br />
160 Capitol Street, Suite 4<br />
Augusta, <strong>Maine</strong> 04330<br />
(207) 621-4390<br />
Attorneys for York Hospital
Prefiled Testimony of Jud H. Knox, President, York Hospital<br />
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Q. What is your name?<br />
A. Jud H. Knox<br />
Q. How are you employed, Mr. Knox?<br />
A. I am President of York Hospital in York, <strong>Maine</strong>.<br />
Q. Why did you submit prefiled testimony, Mr. Knox?<br />
A. I wish to testify in opposition to Anthem’s proposed so-called 6narrow network plans (the<br />
Anthem Plans”).<br />
Q. Why are you opposed to the Anthem Plans?<br />
A. The Anthem Plans purport to be in the nature of narrow networks, 9 which are designed to<br />
reduce costs by utilizing a narrowly selected set of providers 10 who are willing to accept<br />
reimbursement at lower rates than they otherwise would accept 11if they were not<br />
participating in the proposed plans. However, the Anthem Plans 12 do not create narrow<br />
networks; instead they simply exclude important sets of providers 13 from participation,<br />
including York Hospital.<br />
As a result of the Anthem Plans’ exclusion of essential <strong>Maine</strong>15<br />
health care providers, such<br />
as York Hospital, the limited network of providers proposed by 16 these Anthem plans will<br />
be inadequate to serve reasonably the health care needs of tens 17of thous<strong>and</strong>s of <strong>Maine</strong><br />
patients.<br />
Reduced patient access to health care <strong>and</strong> fewer patient choices 19are the exact opposite of<br />
that we should be seeking for <strong>Maine</strong> residents.<br />
Q. Please briefly describe for the Superintendent York Hospital <strong>and</strong> 21 its service areas.<br />
A. York Hospital is the only hospital located in southern York County. 22 York Hospital’s<br />
primary service area is comprised of eight communities: Berwick, 23 Eliot, Kittery, North<br />
Berwick, Ogunquit, South Berwick, Wells <strong>and</strong> York. Exhibit24<br />
A to my testimony shows<br />
the location of the York County municipalities.<br />
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Our secondary 25 service area includes<br />
Kennebunk <strong>and</strong> Lebanon in <strong>Maine</strong> <strong>and</strong> the towns of Portsmouth, 26 Dover, Rollinsford, <strong>and</strong><br />
Somersworth in New Hampshire.<br />
York Hospital includes our main hospital building in York, along 28 with five community<br />
sites <strong>and</strong> 16 separate physician practice sites to care for patients 29 throughout our southern<br />
York County service area.
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Q. Do you know how many Anthem members York Hospital <strong>and</strong>1its providers treat?<br />
A. York Hospital <strong>and</strong> our providers treated approximately 16,0002Anthem members last<br />
year.<br />
Q. What do you, as President of York Hospital, see as the result or 4 the results or the<br />
exclusion of York Hospital from the Anthem Plans’ network?<br />
A. Exclusion of our hospital <strong>and</strong> our providers from the Anthem network 6 will mean that our<br />
patients who are Anthem subscribers will be forced to discontinue 7 treatment at their<br />
preferred, local hospital – York – or with their customary <strong>and</strong> local 8 providers unless they<br />
are willing to pay out of pocket for these services.<br />
Almost all9of these Anthem<br />
subscribers will not be able to afford that. As a result, these patients 10 will have to<br />
discontinue treatment with their primary care providers <strong>and</strong> discontinue 11 treatment with<br />
their customary treating specialists. They will have to decide12<br />
whether they should forego<br />
or postpone treatment, or travel a considerable distance to a new 13 hospital, PCP, or<br />
specialist. If they choose to travel to distant locations to receive 14 medical <strong>and</strong> hospital<br />
care, the additional distance will unnecessarily burden the patients, 15 as well as their<br />
families <strong>and</strong> caregivers, in terms of time, expense <strong>and</strong> emotional 16 dem<strong>and</strong>, <strong>and</strong> will often<br />
mean unnecessary delays in obtaining care. The additional distances 17 <strong>and</strong> times that York<br />
Hospital patients would travel to other York County hospitals18<br />
are shown on Exhibit B to<br />
my testimony. These are average times <strong>and</strong> do not take into account 19 high summer traffic<br />
in York County or winter conditions on two-lane roads. In all 20of York’s service area<br />
towns, Anthem members will need to travel a longer distance21<br />
to reach SMMC <strong>and</strong><br />
Goodall than to reach York Hospital.<br />
Among the 16,000 Anthem members who treated with York Hospital 23 <strong>and</strong> its providers<br />
last year, many will not have the ability or wherewithal to travel 24 to distant hospitals <strong>and</strong><br />
providers. The failure of the Anthem Plans to include local York 25 Hospital providers<br />
necessarily demonstrates, as to these patients, the inadequacy26<br />
of the Plans’ proposed<br />
network.<br />
Q. Given the limited nature of Anthem’s proposed network, do you 28 have any concerns about<br />
the adequacy of the Anthem network?<br />
A. Yes I do.<br />
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Q. Would you please tell the Superintendent what those concerns1are?<br />
A. First, if the ten thous<strong>and</strong>-plus York Hospital Anthem patients elect 2 to incur the burdens of<br />
travel <strong>and</strong> expense in order to treat with Goodall Hospital <strong>and</strong> its 3 providers, or Southern<br />
<strong>Maine</strong> Medical Center <strong>and</strong> its providers, or even <strong>Maine</strong> Medical 4 Center <strong>and</strong> its providers,<br />
I doubt that those hospitals <strong>and</strong> their providers have the capacity 5 to accept these patients<br />
<strong>and</strong> treat them without undue delays. I do not believe that the 6proposed Anthem Plans<br />
have demonstrated how its narrow network will be able to absorb 7 the Anthem members<br />
who have been treating with excluded providers. Even if Anthem 8 could satisfy the<br />
1:2000/PCP:member ratio in the Bureau’s rules, those ratios do9<br />
not tell the whole story<br />
as to capacity <strong>and</strong> network adequacy. After all, the PCP’s <strong>and</strong>10<br />
specialists within the<br />
narrow Anthem network do not care for Anthem members exclusively. 11<br />
This issue was a challenge in the state of Massachusetts upon12<br />
their roll out of an<br />
Exchange-like mechanism even when the network had not been 13 narrowed or limited to a<br />
select group of hospitals. By allowing Anthem to narrow its network 14 at a time when an<br />
influx of patients is entering Exchanges for coverage will exacerbate 15 the problem of<br />
primary care access. This sends the wrong message to the patient, 16 <strong>and</strong> the State of <strong>Maine</strong><br />
can do better.<br />
Q. Is there anything else that causes you to be concerned about the 18 adequacy of the Anthem<br />
network?<br />
A. Yes. Many <strong>Maine</strong> citizens who are currently part of the <strong>Maine</strong>Care 20 program will soon be<br />
uninsured. According to the U.S. Census Bureau Small Area21<br />
Health Insurance Estimates<br />
(SAHIE) 2010 data, there are an estimated 133,000 uninsured22<br />
<strong>Maine</strong>rs under 65 years of<br />
age. The data show that 114,430 of the 133,000 uninsured live 23in households with<br />
incomes under 400% FPL. These uninsured <strong>Maine</strong>rs will be 24 eligible for subsidies for<br />
insurance coverage via the federal Exchange established under 25the Affordable Care Act.<br />
About two-thirds (or 76,072) of these <strong>Maine</strong> uninsureds live in 26one of six counties as<br />
follows: Cumberl<strong>and</strong> (21,701), York (15,204), Penobscot (13,305), 27 Kennebec (9,383),<br />
Androscoggin (9,160), <strong>and</strong> Aroostook (7,319). These are the28<br />
most recent county-level<br />
data. Forty-six thous<strong>and</strong> of these uninsureds live in Cumberl<strong>and</strong>, 29 York, <strong>and</strong><br />
Androscoggin counties. If we assume that even half of these uninsureds were to opt for<br />
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coverage under Anthem via the federal Exchange, this would result 1 in an additional,<br />
substantial influx of new patients on <strong>Maine</strong> Medical Center <strong>and</strong>2<br />
its providers. Again, I<br />
seriously question whether <strong>Maine</strong> Medical Center <strong>and</strong> its providers 3 will have the<br />
capability of reasonably assimilating this very substantial influx 4 of new patients. The<br />
same concern holds true as to the adequacy of the proposed network 5 in northern York<br />
County <strong>and</strong> in Androscoggin County to reasonably absorb the 6anticipated increase in<br />
patients.<br />
And the foregoing does not include any of the 8,800 individual8<br />
or small group<br />
DirigoChoice enrollees enrolled in Dirigo plans as of March 2013, 9 whose coverage will<br />
end on December 31, 2013. Nor do these estimates include any 10 of the 11,750 MegaLife<br />
individual enrollees reported in the company’s 2012 Rule 94511<br />
filing with the Bureau,<br />
who may switch to coverage offered on the Exchange to take12<br />
advantage of the subsidies<br />
or obtain more comprehensive coverage.<br />
These statistics are important. The concept of narrow or limited 14 networks is not new.<br />
These programs have been around the country for several years, 15 but widely used in<br />
metropolitan areas with a variety of different provider/hospital 16options available to the<br />
consumer within a narrow geographic area. For the reason of17<br />
network adequacy alone<br />
<strong>and</strong> concern for the burden on the patient, these narrow or limited 18 network programs have<br />
not been utilized in rural states or rural areas where one hospital 19 or provider system<br />
covers a broad geography. Think of the unintended consequences. 20 By way of example,<br />
an expecting mother in her last trimester begins to experience21<br />
symptoms. It is the middle<br />
of January <strong>and</strong> a snow storm begins. The mother believes these 22 are normal symptoms of<br />
an anticipated normal delivery <strong>and</strong> gets in her car to drive to her 23 closest participating<br />
provider, in Portl<strong>and</strong>, 40 minutes away rather than 5 minutes 24 away at York Hospital.<br />
But, on the way, this mother’s condition worsens, she has more 25profound symptoms, <strong>and</strong><br />
the snow storm gains in strength. At this point, her life <strong>and</strong> that 26 of her expecting child are<br />
in jeopardy. This mother may have had access to York if she27<br />
knew at the time she was<br />
going to be in an emergent situation, but she didn’t. In fact, it28<br />
is these cases, <strong>and</strong> these<br />
situations that have led many states to enact “any willing provider 29 legislation.” If<br />
Anthem was truly concerned about costs, why wouldn’t Anthem allow any willing<br />
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provider to participate in the network at a market rate within reasonable 1 quality<br />
st<strong>and</strong>ards? One would have to assume that the answer is based2<br />
on promises to the<br />
“chosen” providers, rather than what is best for <strong>Maine</strong> consumers. 3<br />
Q. Do you have any other concerns about the proposed Anthem network? 4<br />
A. In addition to there being serious question about the adequacy 5of Anthem’s limited<br />
network to accommodate these tens of thous<strong>and</strong>s of new enrollees, 6 the Anthem network’s<br />
exclusion of York Hospital <strong>and</strong> its providers will effectively prevent 7 southern York<br />
County residents from having a choice of insurance carriers on8<br />
the federal exchange.<br />
These patients will effectively be limited to a single insurer.<br />
And finally, I am concerned about the genesis <strong>and</strong> motive for10<br />
creating the narrow, limited<br />
networks that are at the heart of these plans. It is my underst<strong>and</strong>ing 11 that <strong>Maine</strong> Medical<br />
Center <strong>and</strong> <strong>Maine</strong> Health have had <strong>and</strong> continue to wield significant 12 leverage in the<br />
determination as to what hospitals <strong>and</strong> providers are included13<br />
the Anthem network.<br />
Also it is noteworthy that two of the hospitals which have been 14excluded from the<br />
network are primary competitors of <strong>Maine</strong> Medical Center – Central 15 <strong>Maine</strong> Medical<br />
Center <strong>and</strong> Mercy Hospital. A third is the only York County16<br />
hospital that has not<br />
affiliated with <strong>Maine</strong> Medical Center. If the inadequacies of 17 the proposed Anthem<br />
network are in any way a function of an anti-competitive goal, 18we all should find that<br />
especially troubling.<br />
Additionally, the Blue Cross <strong>and</strong> Blue Shield Association for20<br />
years has touted the<br />
national coverage <strong>and</strong> access for members carrying a BCBS card. 21 This program known<br />
as “BlueCard” allows a member to utilize ANY participating22<br />
<strong>blue</strong> <strong>cross</strong> <strong>and</strong> <strong>blue</strong> <strong>shield</strong><br />
provider nationally. Certain language components m<strong>and</strong>ated23<br />
by the <strong>blue</strong> <strong>cross</strong> <strong>and</strong> <strong>blue</strong><br />
<strong>shield</strong> association are contained in our provider agreements today. 24 So how does a limited<br />
provider network fit into this scheme? Presumably, according25<br />
to contractual language<br />
Anthem would have to allow any member to receive care from26<br />
a participating <strong>blue</strong> <strong>cross</strong><br />
<strong>and</strong> <strong>blue</strong> <strong>shield</strong> provider, like York Hospital. However, they 27 will likely attempt to “steer”<br />
patients away from York through benefit design <strong>and</strong> prior authorization 28 procedures<br />
effectively suggesting to patients that medically necessary care 29cannot be rendered at<br />
their local hospital. The concept of prior authorizations was never intended to<br />
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prevent access to care, it was intended to prevent unnecessary 1care. This new<br />
phenomenon essentially allows Anthem, a third party providing 2 no care for the patient<br />
<strong>and</strong> no idea of local patient needs, to steer patients to other sources 3 of care to their own<br />
benefit. Shouldn’t that concern us as consumers?<br />
There is nothing inherently wrong with trying to identify providers 5 who deliver high-<br />
quality, effective, <strong>and</strong> appropriate health care in a cost-effective 6 manner. However,<br />
networks that deny patients access to prompt health care, irrevocably 7 damage physician-<br />
patient relationships, <strong>and</strong>/or attempt to move patients toward certain 8 providers based for<br />
anticompetitive reasons are inappropriate.<br />
6
EXHIBIT A<br />
to<br />
Testimony of Jud Knox
EXHIBIT B<br />
to<br />
Testimony of Jud Knox<br />
Distances <strong>and</strong> Driving Times to York County Hospitals<br />
Town<br />
No. of<br />
Anthem<br />
Members<br />
Distance <strong>and</strong> Driving<br />
Time to York Hosp.<br />
Distance <strong>and</strong> Driving<br />
Time to SMMC<br />
Compared to York<br />
Hosp.<br />
Berwick 162* 14.6 miles (28 min) 27.7 miles (37 min)<br />
+13.1 miles (+9 min)<br />
Cape Neddick 172* 3 miles (9 min) 29.3 miles (35 min)<br />
+26.3 miles (+26 min)<br />
Eliot 285* 9.4 miles (20 min) 35.2 miles (38 min)<br />
+25.8 miles (+18 min)<br />
Kittery 239* 8.2 miles (13 min) 31.4 miles (32 min)<br />
+23.2 miles (+19 min)<br />
Kittery Point 130* 6 miles (14 min) 33.1 miles (36 min)<br />
+27.1 miles (+22 min)<br />
Moody 41* 10.7 miles (18 min) 17.9 miles (23 min)<br />
+7.2 miles (+5 min)<br />
Ogunquit 168* 9.3 miles (15 min) 20 miles (28 min)<br />
+10.7 miles (+13 min)<br />
North Berwick 139* 21.3 miles (29 min) 20 miles (25 min)<br />
+1.3 miles (+4 min)<br />
South Berwick 300* 10.9 miles (21 min) 26.6 miles (34 min)<br />
+15.7 miles (+13 min)<br />
Wells 462* 15.7 miles (27 min) 14.5 miles (17 min)<br />
+1.2 miles (+10 min)<br />
Distance <strong>and</strong> Driving<br />
Time to Goodall<br />
Hosp.<br />
Compared to York<br />
Hosp.<br />
16.9 miles (27 min)<br />
+2.3 miles (-1 min)<br />
30.5 miles (47 min)<br />
+27.3 miles (+38 min)<br />
24 miles (39 min)<br />
+14.6 miles (+19 min)<br />
32.6 miles (44 min)<br />
+24.4 miles (+31 min)<br />
34.3 miles (48 min)<br />
+28.3 miles (+34 min)<br />
20.5 miles (32 min)<br />
+9.8 miles (+14 min)<br />
19.9 miles (34 min)<br />
+10.6 miles (+19 min)<br />
11.5 miles (20 min)<br />
+9.8 miles (+9 min)<br />
17.6 miles (28 min)<br />
+6.7 miles (+7 min)<br />
14.7 miles (26 min)<br />
+1 mile (-1 min)
York 469* 2 miles (4 min) 25.7 miles (26 min)<br />
+23.7 miles (+22 min)<br />
York Beach 55* 3.2 miles (9 min) 29.5 miles (35 min)<br />
+26.3 miles (+26 min)<br />
York Harbor 49* 0.6 mile (3 min) 26.8 miles (32 min)<br />
+26.2 miles (+29 min)<br />
26.9 miles (38 min)<br />
+24.9 miles (+34 min)<br />
28.5 miles (46 min)<br />
+25.3 miles (+36 min)<br />
28 miles (44 min)<br />
+27.4 miles (+41 min)<br />
(Source: Dartmouth Health Atlas – 2006 data. Distances <strong>and</strong> times calculated using Google Maps)<br />
* Data from Anthem GeoAccess Report for HMO Product (Based on current Anthem members<br />
who will be eligible to move to narrow network product. See Anthem PPA Registration Form).<br />
* Total Anthem members = 2,671