WORCESTER—More than 22,000 Massachusetts residents need to find new health care providers after contract negotiations failed between Point32 Health insurance and major medical facilities Boston Children’s Hospital and UMass Memorial Health.
“This game is insulting to Americans, because people who build up a trusting relationship with a doctor can’t afford to have that relationship torn up,” says Alan Sager, professor of Health Law, Policy, and Management at Boston University School of Public Health.
UMass Memorial Health (UMMH) stated, “We will continue to work collaboratively toward a fair and equitable agreement that enables us to provide the exceptional care that our patients across Central Massachusetts expect and deserve.”
The disruption, which began Jan. 1, could expand to approximately 40,000 patients as Point32 Health faces another likely contract breakdown with Tenet Healthcare, which operates hospitals in Worcester and Framingham areas, including Saint Vincent Hospital.
“Saint Vincent Hospital and MetroWest Medical Center have been trying to reach an equitable, renewal contract with Point32 Health (Tufts/Harvard Pilgrim),” Tenet Healthcare said in a statement. “Our hospitals are important lower-cost, community hospitals. Saint Vincent is the only alternative to UMASS Memorial Medical Center for Worcester and MetroWest is the only hospital located in Framingham.”
UMMH clarified its position on the issue, adding that UMass Memorial Health maintains separate contracts with Point32 Health for their Medicare Advantage products (Tufts Medicare Preferred and Harvard Pilgrim Stride) and their Qualified Health Plan (QHP) product, which is offered through the Massachusetts Health Connector.
According to Sager, “We have just about the most expensive health care in the world here. In Massachusetts, total health care spending this year will be over $125 billion, which comes out to around $18,000 per person.”
Sager added, “We don’t have good calculations nationally, but probably some number of millions of people in the US get letters from a doctor, a hospital or an insurer saying you’re going to be out of network as of a certain day, so good luck finding another doctor or hospital.”
Joseph LaConte, DPM, is a podiatrist who owns his practice in Worcester and alluded to the ever evolving field of health care. “A lot of doctors are leaving or retiring,” he said. “There’s really no incentive to stay in it, which leaves a huge shortage of doctors especially in this area. Asking patients to find a new doctor or health care plan so that they can keep their doctor is a crazy thing.”
LaConte shared that his own doctor retired last year, and even with professional connections, he faced a wait of six to twelve months to secure a new primary care provider. He also noted that the recent shifts in health insurance coverage have led to a loss of some of his own patients.
In UMass Memorial’s statement, it said it does not expect to renew the QHP product agreement and have “therefore sent letters to enrolled patients ahead of the annual open enrollment period to advise them of the managed care plans that we participate in.”
Tenet Healthcare issued a statement: “We want to continue to provide critical healthcare services on an in-network basis for the nearly 50,000 Tufts and Harvard Pilgrim patient encounters we care for annually. Unfortunately, Point32 Health is not negotiating in good faith and our hospitals believe patients should be informed about potential network disruption.”
Point32 Health stated that Tenet’s annual requests for significant rate increases over a multi-year contract could jeopardize both the affordability of health coverage in the Worcester area and patient access to the region’s two local hospitals.
“Despite our best efforts, we were unable to reach an agreement on a new contract with UMass Memorial Health and Children’s Hospital Boston for our Tufts Health Direct members who purchase their insurance through the Massachusetts Health Connector or HSA Insurance,” Points 32 Health said in its statement. “These providers determined that for one product, Tufts Health Direct, they cannot accept the rate necessary to offer affordable coverage to these individuals who receive premium support due to low income. It is our responsibility as a Commonwealth to ensure affordability of these products for this population.”
“One thing we can do is state government could stop standing on the sidelines watching the house burn down and do something useful,” Sager continued. “For one thing, it could follow the law and chapter 224 of the acts of 2012 and identify the caregivers, the hospitals, the doctors, and other caregivers who are needed to protect the health of the public.”
Jon Weissman, chair of the Massachusetts Campaign for Single Payer Health Care (aka Mass-Care), supports a Massachusetts bill to establish universal health care, arguing it addresses gaps in current coverage. He explained that the Massachusetts Health Care Trust’s core purpose is to ensure accessible care for all—a goal, he noted, that isn’t prioritized by public or private health plans. Weissman added that implementing this form of coverage would be the most cost-effective solution for the state.
“The biggest challenge we have is political,” said Weissman. “The so-called ‘leadership’ of the Massachusetts legislature does not have the political will to switch from the ‘market’ approach to Single Payer, even after COVID, hospital meltdowns.”
“It’s crazy to allow insurance companies and hospitals and doctors to fight over this,” Sager argued. “It does disrupt care. It scares patients, especially the most vulnerable patients, who are old and sick and poor. If you’re sick, you’re usually, you’re very often poor, right? You can’t work, or you’re spending all your money on out-of-pocket costs.”
Current Tufts Health Direct premiums average $478 monthly, considerably lower than UnitedHealthCare’s $829 and Blue Cross Blue Shield of Massachusetts’s $809 rates through the Health Connector.
“Unfortunately, it is the people of Worcester and surrounding communities who will ultimately bear the burden of Tenet’s unreasonable demands,” said Point32 Health. “Point32 Health’s two biggest clients in this region are the Group Insurance Commission and the City of Worcester itself. It is these entities, and the members that they cover, who will pay higher costs if we acquiesce to Tenet’s demands.”
Sager pointed out that the U.S. healthcare system loses substantial funds through ineffective treatments, excessive administrative overhead, inflated costs, and fraud. He suggested that meaningful solutions lie beyond ongoing conflicts among insurers, hospitals, and doctors.
“No other country lets patients be treated like 40,000 chips in a poker game between a payer and doctors or hospitals,” he quipped. “We don’t have effective cost controls in health care.”
All affected patients have received a letter notifying them of the changes, as well as how to find a new PCP or provider, or other health coverage. These changes will go into effect at midnight on Dec. 31, 2024.
As the Worcester Guardian marks a year of delivering free, independent digital news to our city, our dedication to this mission strengthens. Please consider a tax-deductible donation to support our ongoing commitment to providing hyperlocal news coverage to Worcester. Scroll to the bottom of our home page to sign up for our daily newsletter
