Anthem drops Bangor heart care provider Enrollees will have to pay more or travel south for treatment

Northern Maine’s only providers of open-heart procedures such as cardiac bypass surgery will soon leave the provider network of the state’s largest health insurer. The change means that Mainers enrolled in any of the plans offered by Anthem Blue Cross and Blue Shield of Maine, including self-insured groups whose benefits are managed by the company, will have to travel south to heart surgery centers in Lewiston or Portland or face higher out-of-pocket costs.

Anthem announced this week that it has rejected a demand for an “extraordinary increase” in the amount it pays to Cardiovascular Surgery, P.A., of Bangor. The practice will leave Anthem’s list of preferred providers effective Sept. 1.

At the state’s Bureau of Insurance, Deputy Commissioner Judy Shaw said the breakdown between Anthem and Cardiovascular Surgery could set a precedent for private insurers who choose to give their members incentives to travel to less expensive practices, rather than give in to demands for higher fees.

Surgeons in the practice include Drs. Felix Hernandez, John Klemperer, Frank DiPietro and Robert Clough. An estimated 10 to 12 percent of the practice’s patients are affected by the break with Anthem.

People enrolled in Anthem’s Medigap plan are not affected by the change.

Clough, who has practiced in Bangor for 18 years, said Thursday that in the process of renewing its three-year contract with Anthem, Cardiovascular Surgery requested a 40 percent increase in fees. Acknowledging a significant increase, Clough said it would have brought Anthem’s payment schedule in line with other private insurers. After a brief back-and-forth, he said, Anthem stopped negotiating.

“So we’re opting out of participation,” he said.

Clough said that while the expenses of running the practice have gone up every year – because of increases in malpractice insurance, the aging population of northern Maine and other factors – income has gone down.

“No doctor comes to Bangor to get rich,” he said. “But I’m trying to run a small business here.” The practice performs 600 or 700 open-heart procedures each year, using the surgical facilities of Eastern Maine Medical Center.

Administrators at the hospital would not comment on the situation.

A spokesman for the insurance company said the practice’s decision means Anthem policyholders will likely pay more if they choose Cardiovascular Surgery for their care.

A Maine regulation known as Rule 850 stipulates that people with private insurance must be able to access an in-network provider of any medical specialty within a one-hour drive of their homes. If there is no in-network provider in that area, the insurer must pay an out-of-network doctor at the same rate it would pay for in-network care.

Surgeons’ fees for cardiac bypass surgery vary widely, depending on a number of factors, including the number of blood vessels affected, the size of the hospital in which the procedure is performed, the geographic region of the country and the patient’s insurance status. According to a national survey published this year by the University of Washington School of Medicine, the average charge is $4,500 to $5,000 per procedure, with a range from $2,000 to $15,000.

Anthem spokesman Mark Ishkanian said Thursday that physicians usually charge more when a patient is covered by an insurance company with which the doctor doesn’t have a contract. Though the percentage of the bill that a patient is responsible for paying may stay the same – typically 20 or 40 percent – it is calculated on a higher amount. And, he added, most plans also require patients to pay a higher per-visit co-payment for out-of-network care.

Self-insured groups with Anthem-administered benefits, including the University of Maine System, Bangor Hydro-Electric Co. and employees of the state of Maine, are not bound by Rule 850 but may be required by their employers to make the trek south or pay more out of pocket.

Ishkanian said Anthem plan members who do travel to Portland or Lewiston for heart surgeries will receive a travel stipend of up to $150 per trip.

In a prepared statement, Anthem president Erin Hoeflinger said the two largest drivers of health insurance costs are fee increases to hospitals, doctors and other providers, and the amount of care patients receive. “With Maine facing a health care cost crisis, it would be irresponsible for us to agree to a fee increase many times greater than market rates,” she said.

Frank John, executive director of employee health and benefits for the state of Maine, said he was disappointed that a reasonable compromise was not reached, allowing Cardiovascular Surgery to stay in Anthem’s network. But he faulted the practice, which he termed a “virtual monopoly” for being insensitive to employers trying to afford health benefits for their workers. John noted that after a cooling-off period, there is still time for the parties to resume negotiations.