Point32 Health, which owns Tufts Health Plan and Harvard Pilgrim Healthcare, said Tuesday that 9,400 patients at its children’s hospital and 17,000 patients at the University of Massachusetts were eligible for coverage as of Jan. 1 with their current insurance. He announced that he would no longer be able to see a doctor. Children’s Hospital gave a different number for affected patients: about 5,000.
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The loss of Children’s and UMass Memorial only affects Tufts health insurance available to customers using the state’s online health insurance marketplace. The plan, called Tufts Health Direct, serves low-income residents and those receiving insurance subsidies.
“Despite our best efforts, we are unable to reach an agreement on a new contract with Massachusetts Memorial Health Children’s Hospital in Boston for Tufts Health Direct members,” Philip Treacy, a Point 32 Health spokesperson, said in an email. I couldn’t do it,” he said. Point32Health will send a letter to all affected members with guidance on how to choose a new primary care provider or specialist, he said.
Monthly premiums for Tufts Health public plans, including Tufts Health Direct, are among the lowest for individuals through the Massachusetts Health Connector, averaging about $478, compared to United’s monthly premiums, which average about $478. Connector Data compared to $829 a month for Healthcare and $809 a month for Blue Cross Blue Shield of Massachusetts, according to Health. Meanwhile, the average monthly premium at Harvard Pilgrim Healthcare is about $705.
Neither Children’s, UMass Memorial nor Point32Health would say how much of a difference there is in their reimbursement rates.
Massachusetts Memorial CEO Dr. Eric Dixon said there was “no conflict” between his health system and Point32 Health. The insurance company simply wanted to pay a lower reimbursement rate than Massachusetts Memorial could pay.
“We would have lost money on every patient we saw, every patient we admitted, every patient we operated on,” Dixon said. He hopes many affected patients will be able to switch insurance companies and continue seeing their doctors.
In an Oct. 16 letter to patients being treated at the children’s hospital, Tufts Health Direct acknowledged the unique challenges faced by children undergoing ongoing treatments such as cancer and dialysis. I admitted something.
“We’re thrilled to be partnering with Point32Health,” said Michael Fopiano, director of member and provider services at Point32Health. He added that under certain circumstances, patients could receive services until January 30, or even longer.
The children’s hospital said in a statement that it was “unable to reach an agreement” with Point32Health.
Point32 Health is also involved in an ongoing contract dispute with Tenet Healthcare, the for-profit health system that operates St. Vincent Hospital in Worcester and MetroWest Medical Center, with hospitals in Framingham and Natick. I am doing it.
St. Vincent’s CEO Carolyn Jackson sent a letter to patients on Oct. 16 saying they will no longer be able to see their doctors starting Jan. 1 unless Tenet and Point32 Health resolve a negotiating impasse. . Point32 Health says that if a new contract isn’t approved by the end of the year, more than 17,000 members will enroll in any plan, including Tufts & Harvard Pilgrim and employer-sponsored plans, as well as plans through Medicaid and Medicare. He said it would affect people.
Patients on Tuesday expressed concerns about the potential for disruption to health care.
Linda Lee, who lives in Dorchester and has insurance through Tufts Health Direct, said her children, ages 9 and 6, have a pediatrician affiliated with Boston Children’s Hospital. If you are referred to a specialist, that doctor is also at Boston Children’s Hospital.
“It’s a children’s hospital. That’s where I always go,” she said. “When my kids get sick, the first thing I think is, ‘Let’s go to a children’s hospital.'”
Because finding a new pediatrician would be so difficult, Lee said she would choose to change insurance companies to keep her child’s primary care physician.
Pedestrians pass by the Longwood Avenue exterior of Boston Children’s Hospital in 2020. Lane Turner/Globe Staff
Alison Blaisdell, an acupuncturist in Fitchburg, said she learned last week that Tufts would no longer cover her family’s physician visits, which are affiliated with Massachusetts Memorial Hospital.
“So now I’m stuck here. If I don’t change my insurance company, I’m going to have to restart my medical practice completely,” she says.
If she stays on the Tufts plan, her options are to travel to Boston to see which providers are still in her network or pay out of pocket for a provider closer to home at Massachusetts Memorial School. Probably. She could have switched to another Tufts plan, but “the rates I received in the mail were astronomical,” she says.
Tenet and Point32Health may still reach an agreement, but both sides are hurling accusations at each other. Tenet accused the insurance company of negotiating in bad faith.
“For over six months, we have been trying to renew our contract with Point32Health to continue our services,” Jackson, whose insurance company customer St. Vincent Hospital, wrote to patients. “However, given the discussions to date, we are not optimistic that an acceptable agreement can be reached in time.”
Point32Health, meanwhile, blamed Dallas-based Tenet for the impasse. The insurer said it was negotiating in good faith, but Tenet has asked for “significant rate increases each year over the course of a multi-year agreement.”
Specifically, the insurers alleged that Tenet required double-digit annual increases in some commercial plans, well above the state’s 3.6% health spending growth threshold.
“These demands threaten both the affordability of health care and access to these two local hospitals for people in the Worcester area,” Point32 Health said in a statement. “We understand that Tenet, as a publicly traded company, puts its shareholders and management first and has different priorities than our company. , the company offered its CEO more than $18 million in compensation.”
Tenet spokeswoman Shelley Weiss Friedberg denied that the health care company is aiming for double-digit growth, but did not provide specific numbers.
David E. Williams, president of the Boston consulting firm Health Business Group, said Tenet and Point32 Health should stop blaming each other and resolve their disputes. Patients and employers who provide health insurance are caught in the middle, he said.
“We’re talking about a 3% inflation rate across the United States,” Williams said. “So if I were a patient or an employer, I would say to health plans and hospitals, ‘Figure out how to keep price increases at that level.’ Don’t make it my problem.”
Point32 Health, which was formed in 2021 through the merger of Tufts University and Harvard Pilgrim University, has suffered serious setbacks recently.
In April 2023, the company was the target of a ransomware attack that halted payments to healthcare providers and forced insurers to use manual workarounds to meet some patient needs. . This devastating cyber attack not only disrupted operations for months, but also damaged the company’s finances. For the first six months of 2024, the insurer reported an operating loss of $155 million on revenue of $4.7 billion, according to an Aug. 15 news release.
In October, Point32 Health announced that CEO Kane Hayes, who led the company for three years, was stepping down “to pursue other opportunities.”
Point32Health, a nonprofit organization, serves 1.9 million members in Massachusetts, Maine, Connecticut, New Hampshire and Rhode Island, the insurer announced in March.
Jonathan Saltzman can be reached at jonathan.saltzman@globe.com. Dana Gerber can be reached at dana.gerber@globe.com. follow her @danagerber6.
