Out-of-network costs to soar for members of Maine health insurance co-op (Portland Press Herald)


The Portland Press Herald posted an article on Oct. 28, 2016 reporting on the outrageous increases in premiums and out of network deductibles for the upcoming year for those unfortunate enough to be stuck with coverage through the Obamacare exchange carrier, Community Health Options.

To read the article, click here.

My response is as follows:

The great irony in this story is that the insurance companies would have us all believe that all out of network coverage is always more expensive, and therefore should be discouraged at all cost. In actuality, the opposite is often true.

For example, a cardiac bypass surgery done at Maine Medical Center, which is arguably the best cardiac hospital in our small state, is billed at about $85,000, assuming no complications. The same surgery performed at Massachusetts General Hospital, arguably one of the best hospitals in the world, and only a two hour ride from Portland, is billed at about half of that. They do several thousand percent more of these surgeries than MMC does, and their quality, and infection rates, are much better. Unfortunately, if a patient chooses to go to Mass General, which is out of network, they do so at their own financial peril. The same would be true for patients who want to go to Dana Farber to treat their cancers. (I understand that only people without insurance pay full price, but why wouldn’t the insurers not want to start negotiating from a lower starting point?)

Even closer to home here in Maine, we see that the ever increasing restrictions placed on physicians, especially PCPs, trying to care for patients, coupled with the always declining pay for doing so, is forcing them to retire early, join the big box practices where care is even more expensive for patients, or opt out of the system entirely. A growing number of doctors are making the transition to a growing model of health care delivery called Direct Primary Care (DPC), where doctors and patients contract with each other, eliminating the costly insurance company middleman. DPC is quite affordable for most Mainers, especially those who are uninsured or have very high deductibles. It should not be confused with high priced concierge medicine. (For an example of such a practice, go to www.ciampifamilypractice.com) Even though the insurance companies are paying nothing for this care, they still work against their patients be not recognizing referrals from these doctors if the patients are in an HMO.

The bottom line is that the insurance companies care not so much about cost as they do about control. They punish patients, and doctors, for thinking outside the box and acting in their own interests.

A far better way to save money and improve choice would be to do away with networks and go to a relative based pricing system where patients could seek high quality, lower cost care anywhere they want with any willing provider. A bill like LD 1305 would have solved the problem of in vs. out of network providers during the last legislative session. Hopefully it will be reintroduced in the coming one.

Michael A. Ciampi, M.D.
South Portland

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