Patients fight as UMass and Children’s hospitals drop Tufts insurance

Stephanie M., who asked that the Globe not use her full last name to protect the family’s privacy, said changing doctors was out of the question.

“Boston Children was amazing,” said Stephanie, a self-employed, licensed independent clinical social worker. “My child needs constant health care. There shouldn’t be any disruptions.” “I have no choice but to change insurance plans,” he added.

But Tufts Health Direct was one of the most affordable plans available. Stephanie pays a monthly premium of $1,480 and has no deductibles. He said he is considering switching to similar insurance offered by the Mass General Brigham Health Plan that covers care at Children’s Hospice. However, the monthly premium is $2,800. “It’s a second mortgage,” said Stephanie, who has secondary coverage through MassHealth, the state’s Medicaid program, because the child is disabled.

In late October, Point32Health, which owns Tufts Health Plan and Harvard Pilgrim Health, told families of 9,400 patients at Children’s and 17,000 at UMass Memorial Health that the insurer had failed to negotiate a new contract for Tufts Health Direct with the two health systems. . (Children’s Hospital gave a different number for affected patients: about 5,000.)

It was one of the biggest disruptions to Massachusetts’ health insurance landscape in years and came at a time when hospitals were grappling with rising costs and insurers were resisting being asked to cover them with higher reimbursement rates.

“It’s definitely a game of chicken,” David E. Williams, president of Boston consulting firm Health Business Group, said of negotiations between health systems and insurers. “They usually get it done, but not always.”

Point32Health, the state’s second-largest health insurer, formed by the 2021 merger of Tufts Health Plan with Harvard Pilgrim Health Services, said Children’s and UMass Memorial want to charge too much for care. Point32Health said it couldn’t afford to pay higher rates and keep premiums affordable.

“We were too far apart, and Boston Children’s and UMass have decided to no longer participate in this plan,” said Philip Tracey, a spokesman for Point32Health. He added: “This is not an uncommon occurrence – providers leave networks for a variety of reasons.

UMass Memorial’s executive director, Dr. Eric Dickson pointed to Point32Health last month. He said the insurance company wanted to pay a lower reimbursement rate for Tufts Health Direct members than UMass Memorial could afford, and that the health system would “lose money on every patient we see, every patient we hospitalize, and every patient we operate on.”

“We urge the parties involved to reach an agreement that will avoid adverse impacts on patients,” state Health and Human Services Secretary Kate Walsh said last month.

But the divide between health systems and insurers appears final.

Patients and their families are caught in the middle and now have to choose between finding a new doctor and choosing more expensive insurance. More than 41 percent of Massachusetts residents said they currently have difficulty affording health care, according to a recent survey by the Center for Health Information and Analysis, a government agency.

Many customers of Tufts Health Direct purchased insurance through the state’s online health insurance marketplace, called the Massachusetts Health Connector. The connector was the model for the insurance exchanges established in the federal Affordable Care Act, or Obamacare. This landmark 2010 law increased the number of insured Americans by making insurance more affordable.

Monthly premiums for Tufts Health Public Plans, which include Tufts Health Direct, are among the lowest premiums offered to individuals through the Connector. The average is around $478, compared with $809 for Blue Cross Blue Shield of Massachusetts and $829 for UnitedHealthcare, according to state data. Premiums are based on income.

Audrey Morse Gasteier, Connector’s chief executive, said Point32Health and the two health systems’ failure to renegotiate a contract caused the biggest upheaval in insurance coverage in Massachusetts in the 13 years she has worked in the state’s market.

He said the agency doesn’t yet know how many people will drop Tufts Health Direct and buy other insurance, given that open enrollment for insurance plans begins Nov. 1 and ends Dec. 23.

“We want to make sure people understand that there are paths to other plans, and that’s part of the market design,” said Gasteier, who encourages Tufts Health Direct customers to contact Connector for guidance.

Children’s Hospital spokeswoman Kristen Dattoli said patients using Tufts Health Direct may receive treatment at out-of-network Children’s with prior authorization if alternative care is not available from the plan’s other providers.

Tracey from Point32Health acknowledged that her company sometimes allows out-of-network care. But Tufts Health Direct has other pediatricians and specialists at Children’s Hospital that members can use instead of doctors, he said.

Of course, making an appointment with a new doctor is often easier said than done.

Tufts Health Direct customer Amy Fogelman of Needham said she was happy with the local pediatrician her 16-year-old daughter went to, but that practice is affiliated with Children’s and will no longer be in-network. Fogelman said she tried to find a pediatrician outside the health system covered by her insurance; None of them were accepting new patients.

Fogelman asked her pediatrician’s office in Needham if she could pay for her daughter’s visits out of pocket, since that would likely be cheaper than buying new insurance. The pediatrician’s office told Fogelman it wasn’t legal, according to Fogelman, who himself founded High Rock Experts, a firm that finds medical experts to testify in legal cases.

As a result, Fogelman expects to switch to a more expensive insurance plan for her daughter next month, which she will purchase through Connector; Fogelman, her husband, and their 20-year-old daughter (who no longer sees a pediatrician) will remain at Tufts Health Direct.

“We can afford it,” Fogelman said of multiple insurance plans. “But I really don’t understand what everyone who gets kicked out of Tufts Health Direct should do (if they have children).”

Tufts Health Direct clients treated at UMass Memorial are also struggling.

Jannatha Coffin, who juggles three part-time jobs teaching and playing music, pays a $208 monthly premium to Tufts Health Direct. The insurance covers the Clinton resident’s primary care doctor and four specialists at UMass Memorial. Two of the experts are monitoring a rare, small, noncancerous lesion near the pituitary gland that was diagnosed about 10 years ago.

“I was very pleased with my care,” she said. “I really don’t want to start over.”

Coffin said he found a plan from Mass General Brigham Health Plan that would cover his care at UMass Memorial, but monthly premiums would more than double to $476.

“I can do that, but of course that will mean making sacrifices elsewhere,” he said. “These are supposed to be affordable health plans, and this really isn’t affordable. I don’t know whether to be mad at the insurance company, the hospital system, or both.”

Jonathan Saltzman can be reached at [email protected].