The breakdown in negotiations leaves patients in the lurch at a perilous time for health care in Massachusetts: there is a shortage of primary care doctors, many hospitals are losing money, and the state is digging out of the mess caused by the bankruptcy of another for-profit hospital chain, Steward Health Care.
And the number of patients scrambling could grow soon to nearly 40,000 because Point32Health, the state’s second-largest insurer, is also at an impasse with a third health system, Tenet Healthcare, the for-profit owner of three hospitals in the Worcester and Framingham areas.
At least 22,000 Massachusetts residents will soon lose access to their primary care doctors and specialists at Boston Children’s Hospital and UMass Memorial Health in Worcester because their insurer, Point32Health, was unable to negotiate a new contract with the health systems.
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Point32Health, the owner of Tufts Health Plan and Harvard Pilgrim Health Care, on Tuesday said 9,400 patients at Children’s and 17,000 patients at UMass will no longer be able to see their doctors there as of Jan. 1 with their current insurance. Children’s Hospital gave a different number for the patients affected: about 5,000.
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The loss of Children’s and UMass Memorial will affect only a Tufts health plan available to customers who use the state’s online health insurance marketplace. The plan, called Tufts Health Direct, serves many people who receive insurance subsidies.
“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,” Point32Health spokesperson Philip Tracey said in an email. Point32Health will send a letter to all affected members with guidance on how to select new primary care providers or specialists, he said.
Monthly premiums for Tufts Health Public Plans, which include Tufts Health Direct, are among the lowest on offer for individuals through the Massachusetts Health Connector, averaging around $478, compared to $829 for UnitedHealthCare or $809 for Blue Cross Blue Shield of Massachusetts, according to Health Connector data. Meanwhile, Harvard Pilgrim Health Care’s average monthly premium is about $705.
Neither Children’s, UMass Memorial, nor Point32Health specified how far apart they were on reimbursement rates.
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Dr. Eric Dickson, chief executive of UMass Memorial, said “there was no fight” between his health system and Point32Health; the insurer just wanted to pay a lower reimbursement rate than UMass Memorial could afford.
“We would have lost money on every patient we saw and every patient we hospitalized and every patient we operated on,” said Dickson. He was hopeful many affected patients will be able to switch insurers and continue to see their doctors.
In an Oct. 16 letter to patients who had received care at Children’s Hospital, Tufts Health Direct acknowledged the particular challenges of children receiving ongoing treatments, including for cancer and dialysis.
“We know that changing providers can be stressful — we’re here to help you find a new provider in our network who meets your needs,” wrote Michael Fopiano, director of member and provider services at Point32Health. He added that under certain circumstances, patients may be able to receive services through Jan. 30 or longer.
Children’s Hospital in a statement said it was “unable to reach an agreement” with Point32Health.
Point32 Health is also involved in an ongoing contract dispute with Tenet Health Care, a for-profit health system that operates Saint Vincent Hospital in Worcester and MetroWest Medical Center, which has hospitals in Framingham and Natick.
Saint Vincent chief executive Carolyn Jackson wrote patients on Oct. 16 that they will lose access to their doctors starting Jan. 1 unless Tenet and Point32Health break an impasse in negotiations. Point32Health said the failure to approve a new contract by the end of the year would affect 17,000 of its members on any of its plans, including both Tufts and Harvard Pilgrim and employer-sponsored plans as well as those through Medicaid and Medicare.
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Patients expressed concern on Tuesday about a potential disruption to their medical care.
Lynda Le, who lives in Dorchester and said she is insured by Tufts Health Direct, said her children, age 9 and 6, have a pediatrician affiliated with Boston Children’s. When they get referred to specialists, those physicians are also at Boston Children’s.
“Children’s Hospital — it’s where I go by default,” she said. “If my kids are sick, the first thing I think of is, ‘Let’s go to Children’s Hospital.’
Children’s, UMass, Tenet patients may be forced to find new doctors or insurance plans
