Wednesday, September 30, 2009

Immigrants left in the lurch again

Kay Lazar in the Boston Globe tells a sad story. Several weeks ago, Governor Patrick and his administration pushed through a plan to help assure that legal Massachusetts immigrants would continue to receive coverage under the state's landmark health care access bill. This was a gutsy move, staving off prejudice and xenophobia, and many of us joined in thanking him for his political courage.

Now, in ways the Governor and his folks could never have anticipated, the insurance company that is providing that coverage has decided to limit the network of physicians and other providers these patients can see. Kay's story outlines this problem. Here are more details that apply to BIDMC and the community health centers affiliated with us.

But the same points apply to Cambridge Health Alliance and Boston Medical Center, the major "safety net" networks in Eastern Massachusetts. CeltiCare’s refusal to negotiate in good faith with key providers that serve this population is jeopardizing and severing thousands of primary care physician/patient relationships and also separating patients from their specialty practitioners.

I summarize some information provided to me by Ediss Gandelman, our Director of Community Benefits:

Over the years, BIDMC has worked tirelessly over the years to ensure that the patients served in our affiliated community health centers have seamless, high quality and culturally competent access to primary care, and to tertiary and specialty services when needed. In downtown Boston, the Fenway, Brighton, Chinatown, Quincy, Roxbury, Dorchester and beyond, BIDMC built these affiliations to prevent poverty, fear and isolation from serving as barriers to responding to the persisting unmet medical needs of these communities.

Given the challenge of administrative burdens and delays in access to care for both primary and specialty care appointments, these community-based affiliations have resulted in timely, efficient and meaningful access to needed care in the appropriate setting for our community health center patients. This is the result of a decade’s worth of effort and investment to ensure that our health centers have electronic health records, and a seamless connection to BIDMC for the real-time sharing of needed laboratory and essential clinical information for their patients.


In short, we BIDMC have created an integrated care delivery system that – for our affiliated community health center patients – means timely, efficient, safe, and linguistically and culturally appropriate care and communication between the community health centers’ and BIDMC clinicians.
(Paul's note: This integration is at the heart of recent policy standards set forth by the state. It is also what is visualized in pending federal legislation.) It crucial to minimizing opportunities for medical error and ensuring high quality care to these patients.

These patients deserve no less.


Immigrants, many of whom have never benefited from a relationship with a primary care physician or a specialty physician, are especially vulnerable to a disruption of this caring relationship—that hard-earned trust will not transfer easily (or at all) to a new provider in an unknown care delivery system. The medical literature is replete with data about how the

patient/physician relationship impacts health outcomes, including adherence to treatment protocols and keeping medical appointments. Being able to continue care with trusted providers and institutions is critical to the health of these patients.

Another element that affects continuity of care and quality and safety is the institutional support for culturally and linguistically diverse patients. BIDMC has invested deeply in its
Interpreter Services department with 47 staff interpreters and more than 54 additional free-lancers. With our health center partners we have also invested significantly in other programs that facilitate access. (For example, Latina and Chinese Cancer Patient Navigators provide compassionate care for vulnerable patients finding their way through a complex medical system). Chinese labor coaches work hand in hand with obstetricians in delivering more than 300 Chinese babies annually, and our Latino mental health team provides invaluable care to the newly arrived who are most prone to depression.

These support systems are not easily replicated and are essential to providing culturally responsive care to CeltiCare members.

9 comments:

Anonymous said...

Looking at this from the outside, I can see on the surface that restricting choice may reduce costs. We've all talked about that, about how you can't have all three, right? And of course the hospitals left out have a self-interest motive to be included.
However, I would certainly like more information about how Partners and Caritas (?) have "creatively" come up with ways to cover these patients and how costs would be increased by expanding the network. If there are reasonable answers to these questions, then so be it. If there are not reasonable answers, then it is just another example of predatory competition in health care, with the patient as loser.
I have to say I was a bit cynical about Celticare when you first published this story some weeks ago, but let's see their data - not be content with their unsupported assertions.

nonlocal

Paul Levy said...

The cost argument, as you suggest, is a canard. All of us would agree to the same rates being charged by those hospitals in this restricted network.

BTW, we anticipate that those charges would be in the same category as Medicaid payments, which are not profitable. This is not about making money for us, BMC, and CHA.

The insurer, though, was not even willing to get that far into the negotiations, though, just saying that they already had enough tertiary capacity -- whatever that means.

And, if they had to limit tertiary providers, why not do it thorugh an open selection/bidding process, perhaps using cost, existing practice relationships, and cultural competence as selection criteria?

Engineer on Medicare said...

At $40 million annually to cover 31,000 persons that is about $1300 per person as a "capitation" fee related to a specific population. It looks like a losing proposition unless they can seriously restrict care by making it difficult to use or by putting severe restrictions on the providers. If it is convenient for people to use, as with BIDMC community health centers, it will get used more. If it is inconvenient to use then it will be used less and will cost less.

How does one operate a capitation system if the patients are permitted to roam from provider to provider where it is hard for the payer to control the access? How would the payments be allocated if a patient went use Caritas for some services and BIDMC for other services?

This element of the process is probably an example of how things will work when the government gets involved with the programs now being considered. People are very uncomfortable with how their health care will change, and how it will be restricted.

Do you believe that the comprensive prostate team services described in the immediately previous blog entry, and a corresponding program for breast and colon cancer, complete with screenings, colonoscopies and Pap smears, will be available? I suspect that there will be few PCPs that will prescribe that kind of comprehensive care at $1300 per head per year.

Richard Wittrup said...

There are two sides to everything. What would be CeltiCare's explanation for what it did? It seems doubtful that the CeltiCare people came to work one morning and said "let's stick it to BIDMC." There must have been a better reason than that.

Paul Levy said...

Richard, the issue is not BIDMC. It is continuity of care for these patients, who would otherwise go to BMC, Cambridge, Lawrence General, and BIDMC, as well as others.

Yes, it would be nice to get a real explanation.

Paul Levy said...

Press release from Massachusetts Immigrant & Refugee Advocacy Coalition:

On Eve of New Immigrant Healthcare Coverage,
"CommCare Bridge" Remains Shaky

BOSTON-- The new plan to provide health coverage for 31,000 immigrants rolls out in the Greater Boston area tomorrow. After cutting recent green-card recipients and other legal immigrants from Commonwealth Care coverage in the FY2010 budget, the state legislature compromised with the Patrick Administration and allocated $40 million -- less than one-third the cost of full CommCare coverage -- for a new managed-care plan, run by CeltiCare. On the eve of the roll out of the new plan, dubbed "CommCare Bridge," numerous questions and concerns remain about the bridge's security.

"We appreciate the efforts and commitment of the administration and CeltiCare to make the best of a bad situation," said Eva A. Millona, Executive Director of the Massachusetts Immigrant & Refugee Advocacy Coalition (MIRA). "But it remains a bad situation.We are concerned about access to affordable and comprehensive health care for these hard-working, tax-paying Massachusetts residents who were singled out for the cuts. In particular, we worry about the adequacy of CommCare Bridge's network of providers, as well as the plan's increased out-of-pocket expenses and its cap on future enrollment."

Currently, all but a small percentage of Boston's 11,500 CommCare Bridge members will need to find new health care providers, since the program's network does not currently include many institutions that have historically served this population, such as Boston Medical Center and Cambridge Health Alliance. Furthermore, with premium costs equal to those in full Commonwealth Care and some higher co-pays, the CommCare Bridge recipients will pay more for less.

"Until we see full restoration of Commonwealth Care coverage for these Massachusetts taxpayers," Millona continued, "we cannot expect them to receive adequate health care. We look forward to working with the Governor and the legislature to restore these important funds."

Anonymous said...

Being nonlocal, I have not been following this closely, but I assume "Commonweath Care" means a subsidy fto meet the state's requirement of health insurance? If so, I wonder at the audacity of the legislature to single out legal (read, tax-paying) immigrants to exclude. It would be analogous to singling out only men (albeit citizens) of the same demographic status, and saying they won't be covered. In other words, these immigrants are contributing all the same things to our society as citizens of the same income level - so is it not a cynical move to exclude them just because they cannot vote you out for doing so? Or what am I missing?
Interesting; just - interesting.

nonlocal

Anonymous said...

This is truly awful treatment of these individuals. They are tax-paying, legal residents, but because they do not have the ability to vote, it is easy to ignore them. I am glad to see that some form of coverage is back, but to limit it in this way - without regard to where these patients live and already get care - is ridiculous and just plain mean.

76 Degrees in San Diego said...

Sad but true. State government is strapped for funds and $41 mill is all they have. Also, the actual contracts for services are not specified, so we don't know what is "covered" and what is "not covered". We also do not know the copayment structure. So, let's say that CelticCare takes 10% for overhead, then the remainder is split 50-50 between hospital services and outpatient primary and specialty care, there is simply not enough $$ to run the plan. So, first, change all the primary care providers...this will delay access by several months for most. Delay reimbursement to the contracted providers....will buy another couple of months. Delay payment for emergency services to noncontracted providers...but the noncontracted still have to be paid by CelticCare for the emergency services. Better to be noncontracted in this situation as I see it.