anthem blue cross and blue shield - Maine.gov

STATE OF MAINE
DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
BUREAU OF INSURANCE
IN RE:
ANTHEM BLUE CROSS AND BLUE
SHIELD REQUEST FOR APPROVAL
OF ACCESS PLANS
Docket No. INS-13-801
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PREFILED TESTIMONY
OF
JUD KNOX
Intervenor York Hospital submits the attached prefiled testimony of Jud Knox, President
of York Hospital, and Exhibits A and B thereto.
Respectfully submitted:
Dated: June 27, 2013
____________________________________
Julius Ciembroniewicz, Esq.
Maine Bar No. 8697
KOZAK & GAYER, P.A.
160 Capitol Street, Suite 4
Augusta, Maine 04330
(207) 621-4390
Attorneys for York Hospital

Prefiled Testimony of Jud H. Knox, President, York Hospital
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Q. What is your name?
A. Jud H. Knox
Q. How are you employed, Mr. Knox?
A. I am President of York Hospital in York, Maine.
Q. Why did you submit prefiled testimony, Mr. Knox?
A. I wish to testify in opposition to Anthem’s proposed so-called 6narrow network plans (the
Anthem Plans”).
Q. Why are you opposed to the Anthem Plans?
A. The Anthem Plans purport to be in the nature of narrow networks, 9 which are designed to
reduce costs by utilizing a narrowly selected set of providers 10 who are willing to accept
reimbursement at lower rates than they otherwise would accept 11if they were not
participating in the proposed plans. However, the Anthem Plans 12 do not create narrow
networks; instead they simply exclude important sets of providers 13 from participation,
including York Hospital.
As a result of the Anthem Plans’ exclusion of essential Maine15
health care providers, such
as York Hospital, the limited network of providers proposed by 16 these Anthem plans will
be inadequate to serve reasonably the health care needs of tens 17of thousands of Maine
patients.
Reduced patient access to health care and fewer patient choices 19are the exact opposite of
that we should be seeking for Maine residents.
Q. Please briefly describe for the Superintendent York Hospital and 21 its service areas.
A. York Hospital is the only hospital located in southern York County. 22 York Hospital’s
primary service area is comprised of eight communities: Berwick, 23 Eliot, Kittery, North
Berwick, Ogunquit, South Berwick, Wells and York. Exhibit24
A to my testimony shows
the location of the York County municipalities.
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Our secondary 25 service area includes
Kennebunk and Lebanon in Maine and the towns of Portsmouth, 26 Dover, Rollinsford, and
Somersworth in New Hampshire.
York Hospital includes our main hospital building in York, along 28 with five community
sites and 16 separate physician practice sites to care for patients 29 throughout our southern
York County service area.

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Q. Do you know how many Anthem members York Hospital and1its providers treat?
A. York Hospital and our providers treated approximately 16,0002Anthem members last
year.
Q. What do you, as President of York Hospital, see as the result or 4 the results or the
exclusion of York Hospital from the Anthem Plans’ network?
A. Exclusion of our hospital and our providers from the Anthem network 6 will mean that our
patients who are Anthem subscribers will be forced to discontinue 7 treatment at their
preferred, local hospital – York – or with their customary and local 8 providers unless they
are willing to pay out of pocket for these services.
Almost all9of these Anthem
subscribers will not be able to afford that. As a result, these patients 10 will have to
discontinue treatment with their primary care providers and discontinue 11 treatment with
their customary treating specialists. They will have to decide12
whether they should forego
or postpone treatment, or travel a considerable distance to a new 13 hospital, PCP, or
specialist. If they choose to travel to distant locations to receive 14 medical and hospital
care, the additional distance will unnecessarily burden the patients, 15 as well as their
families and caregivers, in terms of time, expense and emotional 16 demand, and will often
mean unnecessary delays in obtaining care. The additional distances 17 and times that York
Hospital patients would travel to other York County hospitals18
are shown on Exhibit B to
my testimony. These are average times and do not take into account 19 high summer traffic
in York County or winter conditions on two-lane roads. In all 20of York’s service area
towns, Anthem members will need to travel a longer distance21
to reach SMMC and
Goodall than to reach York Hospital.
Among the 16,000 Anthem members who treated with York Hospital 23 and its providers
last year, many will not have the ability or wherewithal to travel 24 to distant hospitals and
providers. The failure of the Anthem Plans to include local York 25 Hospital providers
necessarily demonstrates, as to these patients, the inadequacy26
of the Plans’ proposed
network.
Q. Given the limited nature of Anthem’s proposed network, do you 28 have any concerns about
the adequacy of the Anthem network?
A. Yes I do.
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Q. Would you please tell the Superintendent what those concerns1are?
A. First, if the ten thousand-plus York Hospital Anthem patients elect 2 to incur the burdens of
travel and expense in order to treat with Goodall Hospital and its 3 providers, or Southern
Maine Medical Center and its providers, or even Maine Medical 4 Center and its providers,
I doubt that those hospitals and their providers have the capacity 5 to accept these patients
and treat them without undue delays. I do not believe that the 6proposed Anthem Plans
have demonstrated how its narrow network will be able to absorb 7 the Anthem members
who have been treating with excluded providers. Even if Anthem 8 could satisfy the
1:2000/PCP:member ratio in the Bureau’s rules, those ratios do9
not tell the whole story
as to capacity and network adequacy. After all, the PCP’s and10
specialists within the
narrow Anthem network do not care for Anthem members exclusively. 11
This issue was a challenge in the state of Massachusetts upon12
their roll out of an
Exchange-like mechanism even when the network had not been 13 narrowed or limited to a
select group of hospitals. By allowing Anthem to narrow its network 14 at a time when an
influx of patients is entering Exchanges for coverage will exacerbate 15 the problem of
primary care access. This sends the wrong message to the patient, 16 and the State of Maine
can do better.
Q. Is there anything else that causes you to be concerned about the 18 adequacy of the Anthem
network?
A. Yes. Many Maine citizens who are currently part of the MaineCare 20 program will soon be
uninsured. According to the U.S. Census Bureau Small Area21
Health Insurance Estimates
(SAHIE) 2010 data, there are an estimated 133,000 uninsured22
Mainers under 65 years of
age. The data show that 114,430 of the 133,000 uninsured live 23in households with
incomes under 400% FPL. These uninsured Mainers will be 24 eligible for subsidies for
insurance coverage via the federal Exchange established under 25the Affordable Care Act.
About two-thirds (or 76,072) of these Maine uninsureds live in 26one of six counties as
follows: Cumberland (21,701), York (15,204), Penobscot (13,305), 27 Kennebec (9,383),
Androscoggin (9,160), and Aroostook (7,319). These are the28
most recent county-level
data. Forty-six thousand of these uninsureds live in Cumberland, 29 York, and
Androscoggin counties. If we assume that even half of these uninsureds were to opt for
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coverage under Anthem via the federal Exchange, this would result 1 in an additional,
substantial influx of new patients on Maine Medical Center and2
its providers. Again, I
seriously question whether Maine Medical Center and its providers 3 will have the
capability of reasonably assimilating this very substantial influx 4 of new patients. The
same concern holds true as to the adequacy of the proposed network 5 in northern York
County and in Androscoggin County to reasonably absorb the 6anticipated increase in
patients.
And the foregoing does not include any of the 8,800 individual8
or small group
DirigoChoice enrollees enrolled in Dirigo plans as of March 2013, 9 whose coverage will
end on December 31, 2013. Nor do these estimates include any 10 of the 11,750 MegaLife
individual enrollees reported in the company’s 2012 Rule 94511
filing with the Bureau,
who may switch to coverage offered on the Exchange to take12
advantage of the subsidies
or obtain more comprehensive coverage.
These statistics are important. The concept of narrow or limited 14 networks is not new.
These programs have been around the country for several years, 15 but widely used in
metropolitan areas with a variety of different provider/hospital 16options available to the
consumer within a narrow geographic area. For the reason of17
network adequacy alone
and concern for the burden on the patient, these narrow or limited 18 network programs have
not been utilized in rural states or rural areas where one hospital 19 or provider system
covers a broad geography. Think of the unintended consequences. 20 By way of example,
an expecting mother in her last trimester begins to experience21
symptoms. It is the middle
of January and a snow storm begins. The mother believes these 22 are normal symptoms of
an anticipated normal delivery and gets in her car to drive to her 23 closest participating
provider, in Portland, 40 minutes away rather than 5 minutes 24 away at York Hospital.
But, on the way, this mother’s condition worsens, she has more 25profound symptoms, and
the snow storm gains in strength. At this point, her life and that 26 of her expecting child are
in jeopardy. This mother may have had access to York if she27
knew at the time she was
going to be in an emergent situation, but she didn’t. In fact, it28
is these cases, and these
situations that have led many states to enact “any willing provider 29 legislation.” If
Anthem was truly concerned about costs, why wouldn’t Anthem allow any willing
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provider to participate in the network at a market rate within reasonable 1 quality
standards? One would have to assume that the answer is based2
on promises to the
“chosen” providers, rather than what is best for Maine consumers. 3
Q. Do you have any other concerns about the proposed Anthem network? 4
A. In addition to there being serious question about the adequacy 5of Anthem’s limited
network to accommodate these tens of thousands of new enrollees, 6 the Anthem network’s
exclusion of York Hospital and its providers will effectively prevent 7 southern York
County residents from having a choice of insurance carriers on8
the federal exchange.
These patients will effectively be limited to a single insurer.
And finally, I am concerned about the genesis and motive for10
creating the narrow, limited
networks that are at the heart of these plans. It is my understanding 11 that Maine Medical
Center and Maine Health have had and continue to wield significant 12 leverage in the
determination as to what hospitals and providers are included13
the Anthem network.
Also it is noteworthy that two of the hospitals which have been 14excluded from the
network are primary competitors of Maine Medical Center – Central 15 Maine Medical
Center and Mercy Hospital. A third is the only York County16
hospital that has not
affiliated with Maine Medical Center. If the inadequacies of 17 the proposed Anthem
network are in any way a function of an anti-competitive goal, 18we all should find that
especially troubling.
Additionally, the Blue Cross and Blue Shield Association for20
years has touted the
national coverage and access for members carrying a BCBS card. 21 This program known
as “BlueCard” allows a member to utilize ANY participating22
blue cross and blue shield
provider nationally. Certain language components mandated23
by the blue cross and blue
shield association are contained in our provider agreements today. 24 So how does a limited
provider network fit into this scheme? Presumably, according25
to contractual language
Anthem would have to allow any member to receive care from26
a participating blue cross
and blue shield provider, like York Hospital. However, they 27 will likely attempt to “steer”
patients away from York through benefit design and prior authorization 28 procedures
effectively suggesting to patients that medically necessary care 29cannot be rendered at
their local hospital. The concept of prior authorizations was never intended to
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prevent access to care, it was intended to prevent unnecessary 1care. This new
phenomenon essentially allows Anthem, a third party providing 2 no care for the patient
and no idea of local patient needs, to steer patients to other sources 3 of care to their own
benefit. Shouldn’t that concern us as consumers?
There is nothing inherently wrong with trying to identify providers 5 who deliver high-
quality, effective, and appropriate health care in a cost-effective 6 manner. However,
networks that deny patients access to prompt health care, irrevocably 7 damage physician-
patient relationships, and/or attempt to move patients toward certain 8 providers based for
anticompetitive reasons are inappropriate.
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EXHIBIT A
to
Testimony of Jud Knox

EXHIBIT B
to
Testimony of Jud Knox
Distances and Driving Times to York County Hospitals
Town
No. of
Anthem
Members
Distance and Driving
Time to York Hosp.
Distance and Driving
Time to SMMC
Compared to York
Hosp.
Berwick 162* 14.6 miles (28 min) 27.7 miles (37 min)
+13.1 miles (+9 min)
Cape Neddick 172* 3 miles (9 min) 29.3 miles (35 min)
+26.3 miles (+26 min)
Eliot 285* 9.4 miles (20 min) 35.2 miles (38 min)
+25.8 miles (+18 min)
Kittery 239* 8.2 miles (13 min) 31.4 miles (32 min)
+23.2 miles (+19 min)
Kittery Point 130* 6 miles (14 min) 33.1 miles (36 min)
+27.1 miles (+22 min)
Moody 41* 10.7 miles (18 min) 17.9 miles (23 min)
+7.2 miles (+5 min)
Ogunquit 168* 9.3 miles (15 min) 20 miles (28 min)
+10.7 miles (+13 min)
North Berwick 139* 21.3 miles (29 min) 20 miles (25 min)
+1.3 miles (+4 min)
South Berwick 300* 10.9 miles (21 min) 26.6 miles (34 min)
+15.7 miles (+13 min)
Wells 462* 15.7 miles (27 min) 14.5 miles (17 min)
+1.2 miles (+10 min)
Distance and Driving
Time to Goodall
Hosp.
Compared to York
Hosp.
16.9 miles (27 min)
+2.3 miles (-1 min)
30.5 miles (47 min)
+27.3 miles (+38 min)
24 miles (39 min)
+14.6 miles (+19 min)
32.6 miles (44 min)
+24.4 miles (+31 min)
34.3 miles (48 min)
+28.3 miles (+34 min)
20.5 miles (32 min)
+9.8 miles (+14 min)
19.9 miles (34 min)
+10.6 miles (+19 min)
11.5 miles (20 min)
+9.8 miles (+9 min)
17.6 miles (28 min)
+6.7 miles (+7 min)
14.7 miles (26 min)
+1 mile (-1 min)

York 469* 2 miles (4 min) 25.7 miles (26 min)
+23.7 miles (+22 min)
York Beach 55* 3.2 miles (9 min) 29.5 miles (35 min)
+26.3 miles (+26 min)
York Harbor 49* 0.6 mile (3 min) 26.8 miles (32 min)
+26.2 miles (+29 min)
26.9 miles (38 min)
+24.9 miles (+34 min)
28.5 miles (46 min)
+25.3 miles (+36 min)
28 miles (44 min)
+27.4 miles (+41 min)
(Source: Dartmouth Health Atlas – 2006 data. Distances and times calculated using Google Maps)
* Data from Anthem GeoAccess Report for HMO Product (Based on current Anthem members
who will be eligible to move to narrow network product. See Anthem PPA Registration Form).
* Total Anthem members = 2,671