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Granite Staters could see the cost of a life-saving ambulance ride more than double under a proposed law change that has New Hampshire’s Insurance Department Commissioner worried.

“I’m deeply concerned,” Commissioner D.J. Bettencourt told NHJournal.

Lawmakers are set to hold hearings this week on SB407, a bill that caps the rate for ambulance services at 325 percent of the Medicaid and Medicare reimbursement rate. The bill is meant to address the Medicaid and Medicare payment shortfalls that already have New Hampshire ambulance services scrambling to stay afloat. But Bettencourt said the proposal would actually set a floor for prices, which will increase costs and shift the burden onto insurance companies and individuals.

“There is no way you’re not going to see upward pressure on premiums,” Bettencourt said

Among the proposed changes in SB407 is a provision that requires health insurance companies to pay the full bill set by the local ambulance services, or 325 percent of the current Medicaid and Medicare reimbursement rate, whichever is lower. Bruce Berke, with the National Federation of Independent Business, said all that does is incentivize local services to set their rates right at the arbitrarily high rate of 325 percent of Medicaid and Medicare.

“The bill will increase premiums for New Hampshire employers who are providing health insurance to their employees but are struggling to afford rising premiums driven by increasing health care costs. The bill’s new mandate would establish government rate setting for the very first time in New Hampshire, essentially creating a ‘minimum charge’ mandate,” Berke said.

The problem the bill doesn’t address is that 80 percent of all patients who require ambulance rides in New Hampshire are on Medicaid or Medicare, Bettencourt said. That means the ambulance companies are significantly underpaid for the vast majority of the patients who require services, forcing them to make up the difference with everybody else.

Dave Juvet, senior vice president of public policy with the New Hampshire Business and Industry Association, said that because the state and federal governments aren’t dealing with the real problem, the cost of an ambulance ride for everyone else could go up 350 percent under the plan, he said.

“That’s just astronomical. I remain mystified why the state feels it needs to step in and somehow establish these rates and a one-size-fits-all rate,” Juvet said.

The effect will be increased insurance costs for employers, which could force them to hire fewer workers at worst or depress wages at best. Juvet said the vast majority of people in New Hampshire get their health insurance through their work.

“Somebody pays for the insurance, and in New Hampshire, that’s employers,” Juvet said.

Drew Cline, with the Josiah Bartlett Center for Public Policy, a free-market think tank, said SB407 keeps people in the dark and hikes the rates they will pay for healthcare.

“The fundamental problem with ambulance billing is that consumers are entirely cut out of the pricing system. No consumer knows how much any given ambulance service will cost or who will pay. SB407 tries to address this by setting an arbitrary number as the default market price, and that number is quite high. Instead of solving the underlying problem, this will just raise prices and insurance costs,” Cline said.

Still, says Chris Stawazs with the New Hampshire Ambulance Association, something must be done, or ambulance companies in the Granite State are going to be forced to shut down.

“Ambulance companies are going out of business because of poor reimbursement rates,” said Stawasz, who works for America Medical Response. “These are the most critical people in the world to be paying appropriately.”

Ambulance billing is complicated and involves private insurance companies dealing with ambulance services that are quasi-government agencies in many cities and towns. The billing process involves both the ambulance service and the insurance company essentially using the patient as a middleman, with bills and checks going to a patient who can get stuck with thousands of dollars in charges.

Stawazs claims SB407 keeps the process just between the ambulance service and the insurance company while bringing the rates up enough to cover the costs. But, he acknowledged, some people will have to pay more.

“Some patients will still have to pay out of pocket depending on deductibles,” Stawazs said.

But Bettencourt is concerned that SB407’s net effect is that health insurance will become out of reach for more people. He’s also worried about people who won’t call 911 and delay getting emergency care when seconds matter because they cannot afford the ambulance ride.

“We want people to focus on getting the help they need,” Bettencourt said.

The regulatory order forcing the Massachusetts General Brigham healthcare system to rein in costs is about to expire, and New Hampshire is wondering what that means for Wentworth-Douglass Hospital in Dover.

“I am concerned about it,” said D.J. Bettencourt, commissioner at the New Hampshire Insurance Department.

Mass General Brigham merged with Wentworth-Douglass in 2018, making the Seacoast region hospital part of MGB’s massive healthcare system. MGB is so big the state of Massachusetts intervened in 2022 to slow the network’s rising patient costs that were warping the Bay State’s healthcare market.

The Performance Improvement Plan imposed by the Massachusetts Health Policy Commission is set to end next month, and there is worry that MGB will start ramping up costs again throughout its system, including at Wentworth-Douglass.

Matt Cover, an employee benefits consultant with Willis Towers Watson, a global insurance advisory firm, said hospitals and large healthcare systems are looking for increases, teeing off of public perception that hospitals suffered during the COVID years.

“As their contracts come up for renewal, hospitals all across the country are demanding unprecedented price increases. These are large corporations trying to squeeze higher profits out of a healthcare system that is already too expensive. Patients, their families, and their employers will ultimately bear the burden of these price hikes,” Cover told NHJournal.

The trend of hospitals consolidating into healthcare systems was long presented as a way to improve care and save money for patients, especially when those mergers needed state approval. But data from a Harvard Medical School report show the savings never happened, and patient care was only marginally better.

“One of the key arguments for hospital mergers and practice acquisition was that health systems would deliver better-value care for patients. This study provides the most comprehensive evidence yet that this isn’t happening,” said Nancy Beaulieu, a research associate in the Department of Health Care Policy at Harvard Medical School’s Blavatnik Institute.

The Massachusetts Health Policy Committee intervened in 2022 after years of skyrocketing costs associated with MGB pushed up costs for all health systems and insurance carriers in the Bay State.

The HPC found Mass General Brigham, the state’s largest health provider, was also charging more than any other provider. In fact, the Committee found that MGB’s commercial contracts cost $293 million from 2014 to 2019.

After posting operating losses last year attributed to inflation and workforce shortages, MGB reported bringing in $102 million in positive operational revenue in the third and fourth financial quarters. The system brought in $18.8 billion during the 2023 fiscal year. MGB’s premium revenue went up to $1.5 billion, a 63 percent increase from the previous year. 

Those numbers represent MGB’s operation under the Performance Improvement Plan to bring down costs. Now that oversight of MGB’s prices is ending next month. New Hampshire has no role in reviewing MGB’s costs and spending. But if the end of the Massachusetts order starts impacting Wentworth-Douglass, Bettencourt said New Hampshire can take action.

“Should that dynamic change or should Wentworth-Douglass be affected as a result of MGB’s attempt to get into compliance with the Performance Improvement Plan, we will work with our commercial insurance carriers, officials at Wentworth-Douglass Hospital, and the New Hampshire Hospital Association to understand its implications for New Hampshire consumers. Should there be adverse consequences, we will respond appropriately within the preview of our regulatory oversight under state law,” Bettencourt said.

The 2018 merger is supposed to leave Wentworth-Douglass locally controlled by its Board of Trustees. However, there are indications that MGB is subsuming more of the identity and control of the Dover facility. Wentworth-Douglass is now rebranded as Mass General Brigham Wentworth-Douglass, and the hospital lost its president and CEO position at the top, replaced by a president and COO position.

Wentworth-Douglass initially agreed to answer questions from NHJournal but did not respond after more than 24 hours.

For 2018, the company was seeking to increase premiums by about 30 percent but is working to organize as a new insurance provider, Minuteman Insurance. It would remain in the ACA exchange but would not be subject to the co-op rules.

“Offering our members a quality, more affordable coverage option has been Minuteman’s mission from day one,” said Minuteman Health CEO Tom Policelli. “We want to continue that mission in 2018 and beyond through the new company we are currently working to organize. Forming Minuteman Insurance Company will allow us to address numerous federal restrictions and work to make our coverage available to more people.”

Nationally, insurers are pulling out of some markets or are seeking to charge higher premiums. Republicans are hoping to repeal President Barack Obama’s health care law, and the Senate is pushing a bill that would leave 22 million more Americans uninsured over the next decade, according to a Monday analysis from the Congressional Budget Office. It would also cut the federal deficit by $321 billion, driven by reductions in Medicaid and smaller subsidies to help people buy insurance.

Minuteman Health is the second co-op to drop out of the New Hampshire market. Community Health Options pulled out for 2017 to focus on Maine, and recently announced it made a surplus after two years of losses. With Minuteman Health exiting, individual and small group customers in New Hampshire will have three options in next year’s exchange: Anthem, Harvard Pilgrim, and Ambetter.