Missing: news headlines

Massachusetts was to be the nation’s test ground for universal health insurance. MassCare has been held up as the model for similar policies on a national level. Its key elements are part of the national healthcare reform measures being proposed for all of us. It is newsworthy what the experiment has learned and how things have been working. Yet, national media has been quiet on news about what is happening… even when the most anticipated benefits have not been proven out, and in fact, have been made worse.

As readers remember, Massachusetts enacted MassCare in 2006 and made it law that everyone must buy health insurance — but only state-approved managed care plans with coverage mandates focused on prevention — and that the State would provide coverage under a government program for growing numbers of people unable to afford insurance. About three-fifths of residents now receive free or subsidized health insurance, according to the Massachusetts government — 16% paid through MassHealth and 41% through the subsidized Commonwealth Care.

It had been sold to the public as saving money through a medical home model with care management focused on prevention, pay-for-performance measures and integrated electronic medical records. Instead of costing less for residents and the government, as we’ve learned, nearly one-third of residents report that their individual healthcare costs have increased, and public spending on health insurance this year are expected to have increased 42 percent since the program was enacted. Government spending on the free and subsidized insurance has doubled just in the past two years and is expected to reach $1.3 billion this fiscal year.

Our tax dollars — $1.35 billion per year in federal funds — are now going towards trying to keep Commonwealth Care, which provides free or subsidized insurance for low- and moderate-income residents, solvent. But the costs are even greater for patients and healthcare providers. These are the costs — to lives and quality of care — that we never hear about on the national news.

Denying claims and slow pay

The most revealing information that’s come out recently was that MassHealth, which covers low-income patients, pays doctors and healthcare providers for their services slower than any commercial health insurance — even more than double the time of Blue Cross and Blue Shields of Massachusetts. The Boston Globe reported figures gathered by athenahealth, which provides billing services for doctors nationwide, which revealed that the complicated and increased governmental regulations and oversight that come with universal coverage doesn’t lead to greater efficiency.

Most stunning to learn was that MassHealth denies claims for payment of medical care dramatically more than any other type of insurance plan — more than four times as often as BCBS, Harvard Pilgrim Health Care or Tufts Health Plan. Tufts denied 4.9 percent of claims, Harvard Pilgrim 5.4 percent, Fallon 5.7 percent and Blue Cross-Blue Shield 6.2 percent — while MassHealth denied 23.8 percent of claims.

Given that MassHealth patients are being managed under a medical home model, doctors are unlikely to be performing extravagantly extra medical care. Wasn’t healthcare reform and universal coverage supposed to protect people from insurance companies that deny legitimate claims for needed healthcare?

Another startling fact that’s come out has dispelled another belief: that the medical home model of managed care and universal coverage would reduce poor people’s reliance on emergency rooms for basic medical care. Instead, the very same percentage of the patient population relies on ERs for basic care today as did before MassCare was implemented in 2006.

“Between 2005 and 2007, the number of ER visits increased seven percent, and total ER costs have gone up 17 percent over the last two years,” according to the Washington Examiner. Patients on state-subsidized insurance use ERs 14 percent more than the average resident and hospitals estimate half of ER visits could have been cared for by a regular doctor.

This week, local news that went unheard by the rest of the country, also told of the impact of Massachusetts’s financially strapped program on patients and on healthcare providers.

We heard, for example, that MassHealth stopped paying for nurses providing home care to special needs children. WBZTV news reported that the pediatric nurses providing this care haven’t been paid since May 12^th and are having to quit because they weren’t being paid, leaving the only option for parents to put their children into nursing homes. Health and Human Services spokesperson issued a statement saying that “MassHealth announced that it would temporarily hold some provider claims to allow us to manage our cash flow for the remainder of the fiscal year, which ended June 30…As we prepared to launch a new computer claims system in May, we sped up payments to providers so that we could ensure a smooth transition to the new system. Because the Legislature budgets a set amount of state funds for MassHealth, speeding up our payments earlier required that we slow down payments as we approached the end of the fiscal year.”

Cash flow is so tight that healthcare providers and hospitals learned a few weeks ago in a memo from the State that some of their pay would be postponed until after July 1^st and that rather than pay them in full, MassHealth intended to evaluate providers based on the severity of the need for payment. Senator Gale Candaras told media that the cash flow problem has affected virtually every hospital and that a lack of communication from state health officials, leaving hospitals inadequate time to prepare, has left hospitals scrambling. The poorest hospitals have been hit the hardest. Some providers told the news that they were worried that a delay in payments could force them to expend their lines of credit and ultimately shut their doors.

Senator Michael Knapik, who is a board member of one hospital already in a precarious position said: “I have no doubt the Commonwealth is broke. If we can’t even pay our bills to hospitals and other vendors, we at least have got to let the representatives of the people know those things.”

All evidence is showing the proposals haven’t worked. And if they don’t work for one state, they won’t work better when they’re multiplied nationwide. But if we never hear what’s happening in Massachusetts, we won’t know what we can expect until comes to us.