News on the state's largest health insurers; the effects of health care reform on coverage; rising premium costs.


A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated

After receiving almost the exact same care at two different hospitals, a patient we're calling Nancy was stunned when she received both bills on the same day. (AP file photo)

After receiving almost the exact same care at two different hospitals, a patient we’re calling Nancy was stunned when she received both bills on the same day. (AP file photo)

The stomach cramp and nausea began one hot Friday evening in August, midway through a vacation on Martha’s Vineyard. The next morning, nearly doubled over in pain, a patient who we’ll call “Nancy” walked gingerly into the emergency room at Martha’s Vineyard Hospital.

Nancy is a 55-year-old former nurse who would prefer not to use her real name because she works with the hospitals in this story.

Even Nancy, who spends hours every day focused on health care costs, would gasp when she saw the bill for this visit.

In the ER, a doctor poked at Nancy’s tender belly and took blood for tests and a urine sample. The doctor ordered a CT scan of Nancy’s abdomen and pelvis, using contrast. It showed bulges, inflammation and thickening in Nancy’s colon. The diagnosis: uncomplicated diverticulitis. Nancy filled a prescription for an antibiotic, took some Advil, and felt better after a few days on a clear liquid diet.

Five weeks later, the diverticulitis monster invaded Nancy’s intestines again. This time she went to an urgent care center closer to home, run by Beth Israel Deaconess Medical Center (BIDMC). A doctor there ordered the same single CT scan of the abdomen and pelvis, again with contrast.

Nancy says the care she received at both places was great. But a month later, when she received the bills and her insurance company’s explanation of benefits for both visits on the same day, she was stunned.

The explanation of benefits show Blue Cross had paid Martha’s Vineyard Hospital almost seven times what it paid BIDMC’s urgent care center for the same CT scan — $3,888.76 vs. $574.97. Continue reading

Tufts Health Plan CEO Jim Roosevelt Stepping Down

Longtime Tufts Health Plan CEO Jim Roosevelt will step down January 1, the company announced Wednesday.

Roosevelt started at Tufts Health Plan as senior vice president and general counsel in 1999. He was appointed CEO in 2005, and since then has grown the insurer from about 600,000 members to more than one million in both private plans and Tufts-managed Medicare and Medicaid plans.

Roosevelt says he’s leaving Tufts in good financial health, but that there are still challenges to dealing with the cost of health care.

Continue reading


First Step In Better Care For LGBT Patients? Find Out Who They Are

The U.S. Department of Health and Human Services said this week that electronic health records must include options for collecting information about gender identity and sexual orientation.

“This is enormously important for transgender patients,” says Dr. Joshua Safer, associate professor of medicine at Boston University. “Knowing how treatments affect men and women, and people of a certain age, is important information for physicians caring for patients. But right now we can’t know that for transgender patients because their medical records aren’t categorized by the correct gender.”

Fenway Health calls the new requirement “landmark.”

Continue reading

As State Agency Fails To Keep Premiums Flat, What’s Ahead For Cost Control In Mass.

There’s a growing list of warning signs that Massachusetts, despite lots of effort, may be losing the battle to control health care costs.

Last month, the Division of Insurance approved a 6.3 percent increase in the base rate for small businesses.

Then, we heard that Massachusetts came in over the target cap for health care spending last year.

And now, an attempt to keep health care premiums flat for the largest employee group in the state has failed.

“It was ambitious, very ambitious,” said Dolores Mitchell, executive director of the state’s Group Insurance Commission (GIC), the agency that manages health insurance for 435,000 municipal, MBTA, state workers, their dependents and state retirees.

“Have we managed to slow cost increases, yes,” Mitchell said. “Have we got our arms around the cost monster, no.”

The GIC is in the middle of a five-year plan.

(Click to enlarge)

(Click to enlarge)

In the current fiscal year, which began July 1st, “it was supposed to be zero, but we didn’t make it,” Mitchell said. The increase this year is 5.7 percent.

The miss means millions of dollars in additional state spending as well as higher costs for the 435,000 people covered by the GIC.

So what happened?

“It has been tough year,” Mitchell said. “Pharmacy going through the roof. The Hep C drug is just a shocker: good for the patients, awful for the budget.”

New blockbuster drugs are just one factor. Mitchell said insurers tell her a big problem is patients who seek care outside of their network. So Mitchell agreed to let insurers require that most members name a primary care doctor and get a referral from that doctor for out of network care. It’s a change she says will save money and improve care.

“All over the country, everybody is saying, medical care is better if you have one doctor who is your major doctor,” she said. Continue reading

Health Connector Sees Rate Hikes For Some, Reductions For Others

Health insurance premiums for Massachusetts residents who purchase unsubsidized health insurance through the Health Connector Authority will see average increases next year of between 2.2 percent and 9.3 percent, according to rates approved by a state board Thursday.

Those who enroll in the state-subsidized private health insurance, known as Connector Care, and those enrolled in dental plans through the Connector can expect to see average premium decreases of 2.1 percent and 1.4 percent, respectively.

The Commonwealth Health Insurance Connector Authority Board on Thursday voted to give its final seal of approval to 15 health insurance companies offering a total of 83 plans for small group and non-group coverage.

Among the plans approved Thursday were the “bronze plans” offered through the Connector, which have low monthly premiums and some pre-deductible doctor visits but come with higher co-pays.

Continue reading

Mass. 2014 Health Care Spending Rises Faster Than State Goal

Massachusetts spent $632 million more on health care last year than it was supposed to, according to a report from the state’s Center for Health Information and Analysis.

The goal, established via a 2012 law, is to keep health care spending in line with the rising costs of other goods and services. Every year the state sets a benchmark. In 2013 — the first year of accountability — Massachusetts stayed well under the cap. But last year, spending shot right past the 3.6 percent target and hit $54 billion, a 4.8 percent increase over the previous year. Continue reading


How Much Is That Eye Exam? Study Probes The Elusive Quest For Health Care Prices

Let’s say you’re having trouble reading this. The words are a little fuzzy. You might need glasses or a new prescription. So you call to make an appointment for an eye exam and ask how much the visit will cost. You’re going to pay for the appointment because your insurance plan has a deductible that you haven’t met.

Seems like a simple question, but be prepared: There’s a good chance you won’t get a simple answer.

“Sometimes people were downright rude,” says Barbara Anthony, senior fellow in health care at the Pioneer Institute. “Other times, staff said they weren’t allowed to give price information over the phone.” (Click the audio player above for Anthony’s interview with WBUR’s Bob Oakes.)

The Pioneer Institute called the offices of 96 dentists, ophthamologists, dermatologists and gastroenterologists (the doctors who perform colonoscopies) last month, asking for the price of five basic services.


The results show that prices vary widely. But getting the information wasn’t easy. Continue reading


Thousands Ruled Ineligible For Mass. Medicaid

Tens of thousands of people have been removed from the state’s Medicaid program during the first phase of an eligibility review, according to figures from Gov. Charlie Baker’s administration obtained by The Associated Press.

The eligibility checks, required annually under federal law but not performed in Massachusetts since 2013, began earlier this year as part of Baker’s plan to squeeze $761 million in savings from MassHealth, the government-run health insurance program for about 1.7 million poor and disabled residents.

At $15.3 billion, MassHealth is the state’s single largest budget expense.

Based on the results of the redetermination process so far, the state was on track to achieve the savings it had hoped for in the current fiscal year without cutting benefits for eligible recipients, said Secretary of Health and Human Services Marylou Sudders. Continue reading

Mass. AG Shifts Health Care Costs Conversation To Behavioral Health

If you have ever tried to get more than a doctor’s appointment for deep depression, alcoholism or a drug addiction, you already know that figuring out where to get care and who will help cover the cost is messy.

Now, that struggle is spelled out in the first health care cost trends report from Attorney General Maura Healey. It takes stock of behavioral health benefits and the low health insurance pay rate for these services in Massachusetts. Healey is shifting the focus of her office’s health care cost report after several, under former Attorney General Martha Coakley, that highlighted the wide gaps between payments made to high- and low-cost hospitals.

Attorney General Maura Healey speaks during a press conference at the State House in June. (Jesse Costa/WBUR)

Attorney General Maura Healey speaks during a press conference at the State House in June. (Jesse Costa/WBUR)

Healey says she’s changing gears because “it’s really important to look at the whole health of the patient.”

“We need to get to a place where we treat people who’ve got mental health, substance abuse issues in the same way we treat patients with diabetes or with cancer or with broken bones,” Healey says.

Seventy-nine percent of Massachusetts residents enrolled in MassHealth or ConnectorCare have coverage that separates general medical care from mental health and substance abuse. For members of commercial health plans. that number is much lower but still significant: 31 percent.  Healey’s report does not say that the separation is necessarily bad, but that the state needs a better system of sharing patient information between medical and behavioral health providers, and more coordination of care.

Continue reading

MassHealth Squandered More Than $500 Million, Audit Finds

The state Medicaid program squandered more than $500 million through unnecessary payments or missed savings opportunities in its managed care program, according to an audit released Tuesday.

The review by State Auditor Suzanne Bump found MassHealth, the state Medicaid program, made $233 million in unnecessary payments for medical services that should have been covered by managed care organizations between October 2009 and September 2014. The audit also says the state could have saved $288 million more through more detailed structuring of managed care contracts.

Bump said that during the five years covered by the audit, MassHealth paid managed care organizations about $12 billion to provide health services to 1.6 million members. Managed care organizations are private health care insurers that agree to fixed, per-member rates to administer and pay for specific categories of health care claims on behalf of MassHealth.

Continue reading