- Please give me your name and current position.
I am Bonnie Post and I am the Executive Director of the Maine Ambulatory Care Coalition.
Please tell me a little about your background.
I have been in my current position for over ten years. I also serve on the Policy Board, Government Affairs Committee and Board of Trustees of the National Rural Health
Association and the Clinical and Health Policy Committees of the National Association of
Community Health centers. I was in the Maine Legislature for eight years, serving as Chair
of the Taxation Committee for the last four.
Please explain what the Maine Ambulatory Care Coalition is.
The Maine Ambulatory Care Coalition is a membership organization and our members
include rural community health centers and programs serving migrant and homeless
populations. Collectively, these programs are called Federally Qualified Health centers
(FQHCs). In addition, our membership includes three Indian health centers. We are a
non-profit organization, providing a broad range of services to our members, including
training, technical assistance, recruitment and in some instances, applying for and
receiving grant funds which support rural community based programs. We are recognized by
the federal Bureau of Primary Health Care as the state's primary care association.
Please describe a Federally Qualified Health center.
A FQHC is a community-based program which provides primary health and other health care
services to underserved populations. In Maine, the underservice is primarily due to
poverty, lack of health insurance and geographic isolation. They are 501(c)(3)
organizations that are owned and operated by community boards. They provide services
regardless of people's ability to pay and have a sliding fee scale for that purpose. In
addition, they accept Medicaid, Medicare and commercial insurance. In most instances,
Maine's FQHCs are the only provider of primary care services in the area and they serve
the entire community, including those who have commercial insurance.
FQHCs receive a portion of their operating funds from the federal Bureau of Primary
Health Care and so have to meet a strict set of programmatic guidelines. As part of their
receipt of grant funds, they are subject to on-site performance reviews that evaluate
their programs from the standpoints of finance, governance and quality assurance.
Collectively, the health centers are staffed by approximately 80 physicians and 40
physician assistants (PAs) and nurse practitioners (NPs)who are employees of the centers.
While most centers have one or more full time physicians, a few of the smaller ones are
staffed primarily by NPs or PAs with a contracted physician providing oversight. In most
instances, the NPs and PAs have their own panel of patients with consultation with or
referral to a health center physician when necessary. It is not a system where the NP or
PA provides triage services.
- Approximately how many patients do the FQHCs see and how many patients have
The health centers collectively have over 70,000 patients with approximately 32,000 of
those enrolled either in traditional or managed care commercial insurance. I do not have
the figures for Blue Cross/Blue Shield, but many centers were early participants in Blue
Cross/Blue Shield's HMO program.
- Is there currently specific language in the Maine statute related to Blue Cross/Blue
Shield contracting with health centers?
Yes, it is Title 24, Subchapter 1, § 2324. However, the language references
"incorporated non-profit health centers" rather than FQHCs since the statute
language was enacted in 1979 and the term FQHC is a relatively new one. However, the
"non-profit health centers" and FQHCs are the same programs. The statute
specifically requires Blue Cross/Blue Shield to provide coverage for outpatient services
provided at FQHCs.
- Has that provision been important to the rural health centers?
Yes. For instance, there have been other commercial providers which have refused to
reimburse for nurse practitioners and physician assistants, but because of the language
relating to Blue Cross/Blue Shield, to the best of my knowledge, centers have not had a
problem with BC/BS in this area. BC/BS has reimbursed health centers for not only
physician services, but for the services of NPs and PAs as well.
- Have questions been posed to Anthem about their relationships with FQHCs?
Yes. We asked several questions to determine the pattern of relationships in other
states to try to determine if it was likely that the current relationship between FQHCs
and Maine BC/BS would change after the sale to Anthem absent any statutory or regulatory
requirements. The questions related specifically to contracting with FQHCs were as
- Please provide information about Anthem's relationship with Federally Qualified
Health centers (FQHCs) in each state in which it operates, including, but not limited to,
all contracts it has in place with Federally Qualified Health centers and/or their
clinicians and copies of provider handbooks provided to enrollees in each state which show
how FQHCs and/or their clinicians are identified. We are particularly interested in
knowing if in all states Anthem contracts directly with the FQHC or if they only contract
with their clinicians and Anthem's practices on listing both the health center and their
providers in provider handbooks.
- Please provide information about any limitations or special conditions Anthem
places on FQHCs, including whether it contracts with FQHCs for all services they provide
and if it requires accreditation or licensing of these entities.
- Please provide documentation relative to the number of FQHCs in each state with
whom Anthem directly contracts.
- Did you receive responses to those questions?
To question number 24, we received the following answer:
The only Anthem subsidiary that deals with Medicaid and thus, tangentially, FQHCs, is
Anthem BC/BS of Connecticut. Anthem does not contract directly with FQHCs. Anthem,
however, does contract with providers who practice in FQHCs. Anthem does not have separate
reimbursement policies for nurse practitioners and physician assistants practicing in
FQHCs. Reimbursement policies for all providers are applied uniformly. In addition,
providers/clinicians in Anthem's provider directory are not specifically identified as
- Do you have a response to Anthem's response?
The statement that "the only Anthem subsidiary that deals with Medicaid and thus,
tangentially, FQHCs, is Anthem BCBS of Connecticut" is troubling. If Anthem's
statement that it does not contract with FQHCs outside of Medicaid in other states is
correct, it seems to demonstrates a pattern of unwillingness to contract with major safety
net providers in rural areas. If that pattern were to continue in Maine and Anthem BC/BS
chose not to contract with Maine's rural FQHCs, these safety net providers would simply no
longer survive, resulting in the loss of services to approximately 70,000 people in
Maine's most rural and underserved communities. Since in most instances, there are few or
no other primary care providers within 30 minutes travel time, those 70,000 individuals,
including those that are covered by BC/BS insurance, would not have reasonable access to
primary care services, IE: primary care services within 30 minutes travel time which is
the state and federal standard.
In relation to the answer to question 25, "Please provide information about any
limitations or special conditions Anthem places on FQHCs, including whether it contracts
with FQHCs for all services they provide and if it requires accreditation or licensing of
these entities.", Anthem indicated that one should refer to the response to question
24. Again, the answer to question 24 seems to indicate that Anthem only deals with FQHCs
through Medicaid and does not contract directly with FQHCs. Therefore, we presume that it
does not contract with FQHCs for non-physician services they may provide, such as
laboratory and x-ray services.
The answer to this question is important since it would indicate whether those services
will be available locally to subscribers and whether the system that provides these
services locally can continue to exist without Anthem/Blue Cross continuing to pay its
fair share of their costs. The question about accreditation and licensing was not
addressed by Anthem. This issue is important because it is very expensive for small rural
sites to become accredited and none of Maine's FQHCs are currently accredited. There are
no licensing provisions for FQHCs or similar entities in Maine.
- Did you ask any other questions about Anthem's relationship with FQHCs and their
Yes. As part of the discovery, we asked the question, "Please provide information
that demonstrates Anthem's reimbursement policies for nurse practitioners and physician
assistants practicing in FQHCs. We are particularly interested in determining whether
Anthem provides a lower reimbursement for nurse practitioner and physician assistant
services in FQHCs than they do for similar physician services in those settings." The
response from Anthem was simply a reference to question number 24.
- Do you have a response to Anthem's response?
Again, question number 24 seemed to indicate that they only contract with FQHCs through
Medicaid arrangements in Connecticut. However, how nurse practitioners and physician
assistants are reimbursed in that instance was not clear. Nurse practitioners and
physician assistants provide a critical component of the health care provider system in
FQHCs. They usually have their own panel of patients and in some instances, they are the
only provider in the isolated center. If Anthem decides that it will in fact contract with
FQHCs but make payments to NPs and PAs practicing in those centers at a lower rate than it
would physicians, again the FQHCs would likely be unable to survive financially, depriving
the entire community, including BC/BS subscribers, with access to health care services
within reasonable driving time since some of the sites are in the state's most isolated
Maine Ambulatory Care Coalition
January 21, 2014