Here are the different rate saver options. Before you change...educate yourself....
Fallon Rate Saver: http://www.fchp.org/GICPORTAL/selectcare.aspx
Tufts Navigator: http://www.tuftshealthplan.com/GIC/GIC.php
Blue Cross: https://www.bluecrossma.com/common/en_US/healthPlansIndex.jsp?levelOneCategory=Health+and+Dental+Plans&levelOneDotFiveCategory=Plans+and+Coverage&levelTwoCategory=Dental+Plans&targetTemplate=titleBodyAddLvl.jsp&repId=Repositories.CategoryMenuRepository.healthPlans.health-dental-plans.plans-coverage.plans-coverage-dental-plans.xml&isLevelThreeSelected=false
Harvard Pilgrim Rate Saver: https://www.harvardpilgrim.org/portal/page?_pageid=213,173255&_dad=portal&_schema=PORTAL
Wednesday, April 8, 2009
DiMasi favors no union approval of health insurance plan
DiMasi favors no union approval of health insurance plan
By Robert Aicardi
Mon Dec 15, 2008, 01:30 PM EST
Braintree - Braintree is among the communities that could be affected by House Speaker Salvatore DiMasi’s wish to strip labor unions of their collective bargaining power in health insurance decisions.
DiMasi, who said on Dec. 8 that local aid could be cut from five to 10 percent in the upcoming fiscal year, intends to introduce legislation that would allow cities and towns to join the state-run health insurance plan without union approval.
“I’m a little blown away right now,” said Christine Giacomozzi, vice president of the Braintree Education Association, when she heard about DiMasi’s plan.
At present, state law mandates a city or town to obtain at least a 70 percent approval from its union members before it can join the Group Insurance Commission (GIC), which provides health insurance and other benefits for more than 294,000 state employees and select other groups.
All 351 cities and towns in Massachusetts, plus 13 regional planning agencies, 61 charter schools, and 55 regional school districts are eligible to join the GIC, but only 17 cities and towns and 10 regional school districts and planning councils have done so.
According to DiMasi, the legislation he is proposing could save municipalities hundreds of millions of dollars, preserve jobs, and prevent property tax increases, but Robert Joseph, the president of the Braintree Police Patrolmen’s Club, is among union leaders who are opposed to it.
“The whole reason we have collective bargaining is so we can work out what’s best for the town and employees, which we’ve been doing at this time,” he said. “Just take democracy out of our hands, why don’t you.”
On the other hand, Geoff Beckwith, executive director of the Massachusetts Municipal Association, applauded DiMasi’s efforts and said that unions are grasping onto an “outdated level of authority” that reinforces inefficiency.
“I think what the speaker did is recognize that collective bargaining with unions is a major block for cities and towns to modernize their health care program,” he said.
“I’m refraining from making any public utterances associated with the GIC for the time being,” Braintree Mayor Joseph Sullivan said.
Because Sullivan and town employees could not come to an agreement before Dec. 1, Braintree won’t enroll, starting in July, in the GIC.
Joseph is the chairman of Brantree’s Public Employee Committee (PEC), consisting of a representative from each of the 13 unions and a retiree representative.
The PEC repudiated the tentative agreement reached on Sept. 23 that failed to obtain the required consent of 70 percent of employees, citing what it regarded as better agreements that other cities and towns reached with those who work for them.
Weymouth, Quincy, Melrose, Watertown, Wenham, Stoneham, Weston, Pittsfield, Norwood, and Randolph negotiated deals with their unions to join the GIC, as required under the Municipal Partnership Law that took effect in July, 2007.
Joseph and Sullivan expressed disappointment after negotiations did not lead to an agreement acceptable to both sides.
“Hopefully, we can work out some kind of deal next year,” Joseph said.
“This is an issue that cannot wait until fiscal year 2011,” Sullivan said. “We need savings in fiscal year 2010, which begins July 1.”
The PEC, Joseph said, is “committed to working with the mayor’s office to make changes that will not only provide cost savings to the town, but also true cost savings to employees that will not be eaten up by higher co-payments.”
According to Sullivan, the final six-year plan that he offered to join the GIC was “fair to all employees and financially sustainable to the town” and would have provided “real dollar savings” toward the rising cost of health insurance.
“I care about all town employees, but my concern extends to the taxpayers as well,” he said.
Chief of Staff and Operations Peter Morin spoke about the future.
“We’ll be looking at any alternative to reduce health costs, whether it means approaching unions to look at co-payments or looking at alternative providers,” he said. “The alternatives we will be exploring will not provide the benefits and savings that the GIC would have provided. Nonetheless, we’re going to explore them.”
Joseph recalled that the PEC submitted a new proposal to Sullivan after employees did not approve the tentative agreement.
“We estimated that the proposal we sent to the mayor would have saved the town about $3 million in the first three years,” he said. “In addition, because we made a six-year proposal, the savings would have grown to several more million over the following three years, based on the suggestion by the mayor’s office that our present plans could increase by an average of 13.5 percent a year. We estimated the potential savings to the town over the six years to be in the neighborhood of $12 million.”
This proposal would have brought the town’s contribution “closer to, but still less than many of, these communities and would have assured that our members would save enough on the premiums to cover the dramatically higher co-payments of the state plan,” Joseph concluded.
Sullivan said, “We originally started with a three-year discussion that expanded to a six-year agreement as an outline. In the end, the town was offering a proposal that three out of every four dollars saved on health care costs would have gone to employees, and the town would have saved enough money to absorb the anticipated local aid cut.”
The mayor argued that it was “intellectually dishonest” to make a comparison between Braintree and other communities like Quincy.
“The fact is that most other communities are increasing their share of the cost to 10 to 12 percent,” he said. “In Braintree with our proposal, we were up to over 18 percent by the end of the agreement.”
Material from GateHouse News Service was used in this story.
Town seeks union vote on GIC insurance plan after negotiation ‘impasse’
Town seeks union vote on GIC insurance plan after negotiation ‘impasse’
By George Derringer / swampscott@cnc.com
Mon Sep 22, 2008, 11:45 AM EDT
Swampscott - The Oct. 1 deadline looms and for the second straight year, negotiations between the Swampscott Board of Selectmen and the town’s employees about health insurance plans have reached an impasse, according to a joint letter from selectmen released Monday morning, Sept. 22.
In the letter signed by all five selectmen, they said negotiations about switching town employees over to the Group Insurance Commission, which provides health insurance to nearly 300,000 state employees and therefore costs less per subscriber, have reached an “impasse.” According to state law, 70 percent of town employees must vote for the change by Oct. 1 each year in order to be eligible for the fiscal year which begins the following July 1.
In Swampscott’s case, selectmen have endorsed the change from a self-funded Blue Cross/Blue Shield plan the town now offers to it employees since it first became available in the summer of 2007. Under the Blue Cross plan, the town pays 60 percent of premiums and employees 40 percent.
A switch to the state plan, called simply “GIC” for short, would have saved the town $800,000 and employees $300,000 last year, the selectmen say in their letter.
However, they contend, the Massachusetts Teachers Association and other unions “seem to have taken the position that no town should join the GIC unless it receives a concession of at least a 10 percent change in the premium split.”
Selectmen said they actually made a concession in a “desperate attempt to close the deal” last fall, but it was rejected by the Public Employee Committee, which negotiates with the town as a collective group of town unions.
“The town made that offer even though every 5 percent increase in its premium share costs the town hundreds of thousands in savings,” selectmen wrote. “None of the unions comprising the PEC put the town’s offer last Fall to a formal vote of its members.”
This year, negotiations began again in May and if the town joined now at the current premium split, the town and employees would still saving hundreds of thousands, selectmen say, but the unions again insisted on having the town pay a higher share of the cost of insurance.
And again, the selectmen offered to have the town pay 10 percent more — but to phase in the change. The unions insisted the phase-in period be only two years, 5 percent each year.
“Under that scenario, the town would lose about $300,000 in savings in those two years, and would be burdened with a 70 percent premium share thereafter,” selectmen said.
Clearly frustrated, selectmen asked a rhetorical question near the end of their statement:
“Why is the PEC insisting on a tactic that undermines the town’s savings when its own members will save hundreds of dollars in premium costs, and any savings by the town will be used to pay union salaries?” they asked before closing with a plea to “let (union) members vote on the town’s last offer so that we can bring this matter to a close one way or another. The PEC owns the town, and it own members, that much at least.”
Text of the letter
Here is the full text of the selectmen’s regarding the GIC issue:
“Once again, we have disappointing news to report concerning Swampscott’s participation in the state’s health insurance program (the “GIC”).
For the second year in a row, we have reached an impasse with the town’s unions comprising the Public Employee Committee (PEC). On Sept. 17, 2008, after months of negotiations, we wrote to the PEC and requested that it put the town’s last proposal to a vote. We received no response to our request.
We are now writing to again urge the unions comprising the PEC to put the town’s last proposal to a vote of their members.
As you may recall, in order for the town and its union employees to participate in the state program, a weighted vote of 70 percent of the PEC must approve, and that approval must be obtained by Oct. 1, 2008.
Last year at this time, the town offered an obvious win-win situation to its union employees. At the current premium split (the town pays 60 percent, the employees 40 percent), joining the GIC last fall would have resulted in savings of over $800,000 to the town in fiscal 2009, and the union employees would have collectively saved hundreds of thousands of dollars in premium costs, certainly well over $300,000.
Even the Massachusetts Teachers Association (MTA) representative who attended some of the sessions last year plainly admitted that while a few PEC members might not benefit under the GIC, the vast majority (over 95 percent) would see significant savings. Much of the town’s savings would have been used to pay salaries and save jobs. In the end, the question begs to be answered. Why wasn’t saving the town $800,000 and saving themselves over $300,000 good enough?
There appear to be several reasons. Based on information provided by the other towns that have either passed or are discussing the GIC, the MTA and other unions seem to have taken the position that no town should join the GIC unless it receives a concession of at least a 10 percent change in the premium split.
The PEC further contends that because the premium split was changed many years ago during negotiated bargaining sessions, concessions should be made now. The PEC also points to premium splits in other towns, ignoring the fact that Swampscott’s health insurance premiums are greater than many towns due to a high utilization rate.
In a desperate attempt to close the deal last fall, the town did offer a concession on the premium, but it was rejected by the PEC. The town made that offer even though every 5 percent increase in its premium share costs the town hundreds of thousands in savings. None of the unions comprising the PEC put the town’s offer last fall to a formal vote of its members.
In addition to its dissatisfaction with the premium split, the PEC claimed it did not have adequate time to consider the full implications of joining the GIC. There is no such excuse this time. Negotiations began in May of 2008, and the PEC has been given a wealth of information concerning the GIC.
The savings that could have been realized last year are gone. If the town now joins the GIC at the current premium split, the town will save approximately $600,000, and the unions’ employees will still save hundreds of thousands of dollars in premiums. Again, the PEC has insisted on changing the premium split, and reducing its share.
Recognizing that, the town made the difficult concession of going to a full 10 percent increase in its premium share, phased in over a number of years. That gave the PEC its 10 percent reduction, exactly what it asked for, but allows the town to reap the full savings (about $600,000) in the first year.
But even that wasn’t good enough. Instead, having gotten the 10 percent, the PEC has insisted that the premium change be aggressively implemented in the first two years (5 percent the first year, and 5 percent the second year).
Under that scenario, the town would lose about $300,000 in savings in those two years, and would be burdened with a 70 percent premium share thereafter. By way of comparison, that amounts to about half the amount of savings the town would have realized in fiscal 2010 under the standard 60/40 split.
Again, the question must be answered. Why is the PEC insisting on a tactic that undermines the town’s savings when its own members will save hundreds of dollars in premium costs, and any savings by the town will be used to pay union salaries?
Despite any suggestion otherwise, the GIC is an excellent program offering first-rate insurers like Harvard Pilgrim, Tufts and Fallon, and is the same program used by nearly 300,000 state employees. Indeed, the MTA’s own representative has acknowledged that the plans offered under the GIC are comparable to the town’s current plans.
It is time for the PEC to let its respective members vote on the town’s last offer so that we can bring this matter to a close one way or another. The PEC owes the town, and its own members, that much at least.
s/Swampscott Board of Selectmen
MASSACHUSETTS ACT OPENING STATE HEALTH PLAN TO MUNICIPALITIES
January 11, 2008 | 2008-R-0039 | |
| MASSACHUSETTS ACT OPENING STATE HEALTH PLAN TO MUNICIPALITIES | ||
| | ||
| By: John Moran, Principal Analyst | ||
You asked for a summary of the Massachusetts Municipal Partnership Act's provisions that permit municipalities to join the state health plan to insure their employees and retirees.
SUMMARY
The law, enacted in July 2007, gives cities and towns the option to obtain health insurance for their employees and retirees though the Group Insurance Commission (GIC). GIC was previously open only to state employees and retirees, retired teachers, and Springfield city employees and retirees (due to the city's financial crisis). Under the partnership act, decisions to participate in GIC are made by agreement between the municipality and a public employee committee, which must include representatives from each municipal union.
Municipalities pay all costs associated with purchasing health insurance through GIC — there is no state subsidy. Towns are expected to save money through access to the state's large purchasing pool.
Five towns and seven regional school districts met the initial October 1, 2007 application deadline to join GIC. This report includes details of the town of Saugus's process to join.
BACKGROUND ON MASSACHUSETTS' GROUP INSURANCE COMMISSION
The commission is a quasi-independent state agency created by the legislature in 1955 to provide and administer health insurance and other benefits to the Commonwealth's employees, retirees, and their dependents. Over the years, additional groups were added to GIC's jurisdiction: housing authority personnel, retired teachers, employees of some municipalities, and a small group of long-time retired municipal employees.
It provides a menu of 11 different plans: two indemnity plans, several HMOs, and several preferred provider organizations (PPOs). It also offers other insurance products (life insurance) and pre-tax programs for employees (health care spending accounts and dependent care assistance program).
Over 286,000 people are enrolled in GIC plans. Its FY 2008 appropriation is $ 1. 17 billion. It is governed by an 11-member, governor-appointed commission.
PARTNERSHIP ACT OVERVIEW
The act requires a municipality, regional school district, county, or other political subdivision of Massachusetts to reach an agreement with its public employee committee to join GIC. Under the act, such an agreement is the only way to transfer employee health insurance coverage to GIC.
The law greatly limits what areas of health care coverage remain subject to collective bargaining. Through the agreement with the municipality the employee committee can only negotiate (1) whether or not to join GIC, (2) the employee premium contribution, and (3) whether to opt out of CIG at the end of the term set in the agreement (the law states the term must be either three or six years).
Under the law GIC determines:
1. health benefits,
2. design and types of plans,
3. the insurance carriers,
4. doctor copays,
5. plan deductibles,
6. plan members' rights and responsibilities, and
7. plan costs, excluding employee contributions.
The law specifies these items are not subject to (1) collective bargaining; (2) the agreement between the employee committee and the town; or (3) binding arbitration, which may be included in the agreement for issues such as interpreting the agreement.
Other requirements the municipality must meet include:
1. agreeing to offer all GIC plans,
2. agreeing that all Medicare eligible retirees must apply to Medicare or prove they are already on it,
3. committing to GIC for either three or six years,
4. agreeing to pay any premium penalty the federal government assesses for eligible retirees who fail to sign up for Medicare, and
5. agreeing to pay GIC an administration fee of up to 1% (which may be included in the premium total for purposes of determining the employee contribution percentage).
PUBLIC EMPLOYEE COMMITTEE
The employee committee must be made up of representatives of each union the municipality bargains with plus one retiree member. The retiree member must be designated by the Retired State, County and Municipal Employees Association.
Any agreement with the municipality must be approved by a 70% weighted vote of the employee committee. The retiree representative gets a vote weighted at 10%. The remaining 90% is divided among the union representatives with each vote weighted according to the proportion of a union's members who are eligible for GIC insurance compared to the total number of eligible municipal employees. The supermajority requirement appears intended to prevent an agreement from moving ahead without overwhelming union support.
Agreements reached under this law are binding upon all employees and others subscribing to the health plan.
MUNICIPAL-EMPLOYEE AGREEMENT
The law states the agreement reached between the town and the employee committee, when accepted by GIC, supersedes any conflicting provisions of any pertinent union contracts. The agreement itself may include procedures (such as arbitration) for resolving negotiation impasses for a successor agreement. During any time when no successor agreement is approved, the prior health care agreement terms remain in effect.
Any dispute over the interpretation or application of the agreement may be submitted, upon the request of either the town or the employee committee, to binding arbitration under the labor provisions of the American Arbitration Association. Such a request must be approved by 70% of the employee committee's weighted vote or by a majority of the appropriate political subdivision (city council, board of selectmen, regional board of education, etc. ).
ONE CLAIMS EXPERIENCE POOL
The law places all new GIC members into a single, large pool with all covered Massachusetts state employees, retirees, and dependents and any previously covered members (such as retired teachers and Springfield city employees and retirees). The law states the claims experience of all these members will be pooled together.
GIC previously maintained two pools, one with state employees and the other with retired teachers and other municipal members. Now, all new members go into the larger state employee pool. But GIC will keep the smaller pool until its members gradually switch over to the larger one.
SELF-INSURED AND FULLY INSURED PLANS
Some GIC plans are self insured and others are fully insured. Currently, the indemnity and PPO plans are self-insured and the HMO plans are fully insured, according to Lisa Boodman, GIC general counsel.
GIC is currently bidding for new contracts and, depending on the offers that come in, Boodman said what is self-insured or fully insured may change under new contracts.
DEADLINES
The law sets an annual October 1 deadline for municipalities to submit the agreement with the employee committee to GIC. If the agreement meets all of GIC's requirements, the municipal employees and retirees start getting coverage under GIC on the following July 1 (the beginning of the GIC fiscal year). Any members already in GIC, such as retired teachers, at the time of the transfer become members under the Municipal Partnership Act, which includes all the terms previously mentioned.
WITHDRAWAL PROCEDURES
The municipality-employee agreement must call for either three or six year commitments to GIC, and at the end of that time the employee committee, the town, or both jointly can move to withdraw their members from GIC. The agreement must specify the withdrawal procedures.
The decision and notice to withdraw must be made to GIC by October 1 of the year prior to the effective date of the withdrawal. All withdrawals take effect on July 1 following this notice. Withdrawal from GIC means the town must bargain with each union individually for health care coverage under the standard collective bargaining law.
The partnership act also bans a town from charging members more than 25% of the premium cost for health coverage after withdrawal if the members were covered by GIC before the town entered GIC via the municipal-employee agreement. In other words, it protects the retired teachers and others who were already in GIC before passage of the Municipal Partnership Act.
OTHER PROVISIONS
The law contains other provisions such as:
1. procedures for the state to follow if a town fails to pay GIC on time;
2. expansion of GIC governing board with two municipal members, one representing municipal management and one unions (another two will be added after there are at least 45,000 municipal subscribers added under the law); and
3. authority for GIC to issue regulations to carry out the new law.
SAUGUS JOINING GIC
Savings
The town of Saugus was the first municipality to join GIC under the provisions of the Municipal Partnership Act. The town estimated it will save between $ 1 million and $ 2. 5 million a year by joining GIC. But the town personnel administrator, Fran Trainor, cautions that the arrangement is so new, exact savings are not clear yet.
The town now pays GIC $ 700,000 a month to cover 877 employees, retirees, and dependents. Previously Saugus self insured, and its monthly cost fluctuated depending upon the claims submitted. It was usually between $ 700,000 and $ 900,000 a month. Since retired teachers were in GIC, Saugus already had 209 retired teachers covered by GIC. They cost the town another $ 1. 7 million a year.
With GIC some administrative costs come as a surprise. “We just got a bill for $ 7,000 for the coming open enrollment period for printing the enrollment documents. I questioned the cost but they told me they couldn't print any less,” Trainor said.
She also noted that GIC is currently putting its contracts out to bid, and the town will have to wait and see what the new costs will be when that process is finished.
The Process of Switching to GIC
Legislators included an amendment in the partnership bill that permitted Saugus to join GIC effective January 1, 2008 – six months earlier than any other town – due to Saugus' dire fiscal situation. The bill was signed into law on July 27, 2007 and the deadline to file the municipality-employee agreement was October 1 (see Attachment 1 for copy of the agreement). Trainor said it was a difficult task to get a 70% favorable vote from the employee committee on an agreement. “There were many meetings. It was a lengthy and complicated process educating the employees,” she said.
The Massachusetts Teachers Association (MTA) had the greatest number of employees so it represented about 50% of the vote. The MTA pushed strongly for the switch to GIC, Trainor said. She said MTA representatives met separately with the employee committee and even hired a consultant to hold educational sessions for them.
But the MTA also had certain demands of the town. It wanted its retirees to continue to pay a 10% employee premium contribution for any plan offered under GIC. While in the beginning all town unions agreed they would not use their vote over whether to go with GIC as a bargaining chip in their own contract negotiations with the town, the MTA did just that in the 11th hour.
“We knew we couldn't reach the 70% [yes vote] without the MTA because they were 50% of the vote. And the other unions were upset that the teachers forced their contract to be settled before the employees committee agreement was settled with the town,” Trainor said.
The teachers were given a five-year contract instead of the usual three-year term.
Trainor noted the municipality-employee agreement benefits employees by including:
1. PPO plans (previously the town did not offer one) with the town paying 90% of the premium and employees paying 10%,
2. the HMO plans also have a 90/10 contribution split,
3. indemnity plans have a 75/25 contribution split (previously the split was 65/35), and
4. town pays 60% of the Medicare B monthly cost (previously it made no contribution to this).
The employees had to accept somewhat higher copays, no dental coverage for children under 12, and they all have to move onto Medicare when they are eligible. Moving all eligible retirees to Medicare B or proving that they were already on Medicare B, was a challenge under the short time frame.
“We spent many days calling seniors at home, in nursing homes, trying to get them to enroll in Medicare or give us the paperwork that shows they were already in,” Trainor said.
Once the agreement was in place, the town had three months to educate its employees and retirees about the new health care options and have them all enroll in a new plan so the new coverage could smoothly take effect on January 1, 2008.
RELATED WEB LINKS
Massachusetts Municipal Partnership Act: Text of law is hosted on the Metropolitan Area Planning Council (Boston region) website: www. mapc. org/regional_planning/legislative/HealthCareActionCenter/7_26_07_Updates/TextOfLaw. pdf
C To Base Co-Pays On Hospital RatingsBy Martha Bebinger
C To Base Co-Pays On Hospital RatingsBy Martha Bebinger
Listen to story (Real Audio)
BOSTON - April 07, 2009 - First it was doctors, now it's hospitals. Starting in July, more than 300,000 residents who get health coverage through the Group Insurance Commission will pay more to go to some hospitals than others.
Putting hospitals in one of three tiers, based on the cost and quality of their care, is part of the latest effort by the GIC to hold down healthcare costs.
Here's how this will work. If you're a state employee, your health plan will develop a rating system for hospitals that is supposed to be based on the cost and quality of their care.
At a tier-one hospital, your co-payment for an inpatient stay would be in the range of $200. But going to a tier-three hospital would cost you $750 or so, depending on your plan.
The Group Insurance Commission started a similar system for doctors several years ago. And although the Massachusetts Medical Society has sued the GIC over the program, GIC Director Dolores Mitchell says it's time to expand the practice to the hospitals where physicians work.
DOLORES MITCHELL: We are paying an enormous amount of money to cover our enrollees and we know that there is enormous variability in the quality of care delivered in these institutions. It seems to me it's incumbent on us to try to get a handle on that.
JOE KIRKPATRICK: Patients should know the difference about the costs for hospitals and select those that are most cost-effective.
Philosophically, says Joe Kirkpatrick with the Massachusetts Hospital Association, hospitals agree with the idea of tiered co-payments. But the MHA has problems with the GIC plan.
There is no uniform measurement. Each health plan is using its own cost and claims data and different national quality measures. Kirkpatrick says a hospital might be tier-one with one insurer, but a level two or three with another.
KIRKPATRICK: And that gets to be quite confusing for the recipients and the beneficiaries of the health plans.
KAREN GRANOFF: And, as we talked about also, consumers largely go where they're referred by their physicians, number one.
Karen Granoff is also with the MHA.
GRANOFF: Number two, the ability to chose is probably dependant on whether it's an elective procedure where you have the luxury of looking at different providers, versus something that is more emergent.
But, right now, the GIC does not plan to factor in whether a patient is rushed to an emergency room with appendicitis or has had months to plan where to deliver her baby.
Health Care for All's Georgia Maheras says the consumer group has not decided whether to support tiering hospitals as a cost saving measure.
GEORGIA MAHERAS: We want to make sure that whatever happens, it's transparent, that consumers are really educated along the way and that there can be course corrections if something is really harming people in the future.
Maheras and others also note that tiering to improve the quality of care or where patients go to get it is not well tested. Tufts Health Plan has one option that includes tiered co-payments for hospitals, but the idea has not caught on until now.
Paul Ginsburg, president of the Center for Studying Health System Change, says in the few other areas of the country where insurers have proposed different co-payments based on a hospital's performance, major hospitals refused to participate and insurers backed off.
PAUL GINSBURG: Now this is a situation where perhaps the GIC has the clout to bring this about.
And Ginsburg says there?s potential for significant savings in Greater Boston if consumers can be persuaded to stop going to more expensive teaching hospitals for routine procedures rather than community hospitals that are often cheaper and rate as high or higher on quality.
GINSBURG: In the studies that we've done around the country, the Boston area stands out in the number of people that like to go to academic medical centers for fairly routine procedures.
Tiering hospitals is one of a half dozen other more modest co-payments that residents served by the GIC will see in July. The agency, after budget cuts, has a $60 million deficit this year and may face more state budget cuts next year.
GIC Director Dolores Mitchell expects the commission can balance its budget next year with these changes and if the legislature agrees to Gov. Patrick's plan to increase the share of premiums that moderate- and higher-income employees pay. Unions are pushing hard against the premium increases.
Listen to story (Real Audio)BOSTON - April 07, 2009 - First it was doctors, now it's hospitals. Starting in July, more than 300,000 residents who get health coverage through the Group Insurance Commission will pay more to go to some hospitals than others.
Putting hospitals in one of three tiers, based on the cost and quality of their care, is part of the latest effort by the GIC to hold down healthcare costs.
Here's how this will work. If you're a state employee, your health plan will develop a rating system for hospitals that is supposed to be based on the cost and quality of their care.
At a tier-one hospital, your co-payment for an inpatient stay would be in the range of $200. But going to a tier-three hospital would cost you $750 or so, depending on your plan.
The Group Insurance Commission started a similar system for doctors several years ago. And although the Massachusetts Medical Society has sued the GIC over the program, GIC Director Dolores Mitchell says it's time to expand the practice to the hospitals where physicians work.
DOLORES MITCHELL: We are paying an enormous amount of money to cover our enrollees and we know that there is enormous variability in the quality of care delivered in these institutions. It seems to me it's incumbent on us to try to get a handle on that.
JOE KIRKPATRICK: Patients should know the difference about the costs for hospitals and select those that are most cost-effective.
Philosophically, says Joe Kirkpatrick with the Massachusetts Hospital Association, hospitals agree with the idea of tiered co-payments. But the MHA has problems with the GIC plan.
There is no uniform measurement. Each health plan is using its own cost and claims data and different national quality measures. Kirkpatrick says a hospital might be tier-one with one insurer, but a level two or three with another.
KIRKPATRICK: And that gets to be quite confusing for the recipients and the beneficiaries of the health plans.
KAREN GRANOFF: And, as we talked about also, consumers largely go where they're referred by their physicians, number one.
Karen Granoff is also with the MHA.
GRANOFF: Number two, the ability to chose is probably dependant on whether it's an elective procedure where you have the luxury of looking at different providers, versus something that is more emergent.
But, right now, the GIC does not plan to factor in whether a patient is rushed to an emergency room with appendicitis or has had months to plan where to deliver her baby.
Health Care for All's Georgia Maheras says the consumer group has not decided whether to support tiering hospitals as a cost saving measure.
GEORGIA MAHERAS: We want to make sure that whatever happens, it's transparent, that consumers are really educated along the way and that there can be course corrections if something is really harming people in the future.
Maheras and others also note that tiering to improve the quality of care or where patients go to get it is not well tested. Tufts Health Plan has one option that includes tiered co-payments for hospitals, but the idea has not caught on until now.
Paul Ginsburg, president of the Center for Studying Health System Change, says in the few other areas of the country where insurers have proposed different co-payments based on a hospital's performance, major hospitals refused to participate and insurers backed off.
PAUL GINSBURG: Now this is a situation where perhaps the GIC has the clout to bring this about.
And Ginsburg says there?s potential for significant savings in Greater Boston if consumers can be persuaded to stop going to more expensive teaching hospitals for routine procedures rather than community hospitals that are often cheaper and rate as high or higher on quality.
GINSBURG: In the studies that we've done around the country, the Boston area stands out in the number of people that like to go to academic medical centers for fairly routine procedures.
Tiering hospitals is one of a half dozen other more modest co-payments that residents served by the GIC will see in July. The agency, after budget cuts, has a $60 million deficit this year and may face more state budget cuts next year.
GIC Director Dolores Mitchell expects the commission can balance its budget next year with these changes and if the legislature agrees to Gov. Patrick's plan to increase the share of premiums that moderate- and higher-income employees pay. Unions are pushing hard against the premium increases.
Physicians Cite Continuing Problems with Fourth Year of GIC Tiering
Physicians Cite Continuing Problems with Fourth Year of GIC Tiering
Vital Signs: April 2009Ann T. Nutt, M.D., a Dorchester pediatrician, vividly recalls the day this past February when she opened her mail to find that she would no longer be a tier 1 physician after July 1 under the state Group Insurance Commission’s (GIC) Clinical Performance Improvement program (CPI). The health plans under the aegis of the GIC insure about 300,000 state and municipal workers, their families, and retirees.
In fact, Dr. Nutt discovered she was now ranked in tier 3 — which meant, among other things, higher copays for her patients.
“I was irked, discouraged,” she said. “The insurance company’s letter was hard to understand. It took a couple of reads to interpret what the numbers meant.”
Finally, she called the health plan. A representative told her that the “efficiency” part of her record was excellent. “It’s quality that’s killing you,” she was told.
“I care about my efficiency,” Dr. Nutt said. “But I really care about my quality.” The insurer instructed Dr.Nutt to send a letter listing the reasons why her rating should be reconsidered. “What they didn’t do was give me a list of patients linked to the claims so that I could look in the chart, see what was done, and make an effective case for myself,” she said. Eventually she got the insurer to send her detailed information used in her ranking. That data, she said, showed that in 127 opportunities to be “compliant,” she had complied 115 times.
“Then I was really irked,” Dr. Nutt said. Heeding MMS advice that members move quickly to appeal their rankings, she formally appealed within the tight deadlines set down by insurer.
Dr. Nutt finally determined that her fall from the highest to lowest physician rating occurred because, in treating certain adolescent girls, she prescribed birth control pills without requiring chlamydia screening. Dr. Nutt knew that the girls in question were not sexually active and thus did not need to be screened for the sexually transmitted bacterium. Apart from their use as contraceptives, birth control medications, she added, are appropriate treatment for intense menstrual pain, acne, or polycystic ovary syndrome in such patients.
“But in reviewing my record, they just saw the claim for prescribing the medication without also seeing a claim for ordering the screening,” she said.
Despite her clinically sound explanation, the insurer denied Dr. Nutt’s appeal of her tier 3 ranking. “The denial was just a form letter,” she said. “It seemed as though they hadn’t even read my letter explaining everything.” After calling the insurer yet again, Dr. Nutt was told that a letter to pediatricians affected by the chlamydia measure was forthcoming and that her rating would probably be upgraded to tier 2. As this issue of Vital Signs went to press, she had not received the letter nor confirmation of any tier change.
Dr. Nutt is not alone in her frustration with the controversial GIC rankings. As it has every year since the GIC “Select and Save” tiering program began in 2006, the MMS has been inundated with calls from members unhappy with their rankings.
“We’ve gotten reports of physicians who are retired being put in tier 1,” said Bruce S. Auerbach, M.D., the MMS president. “Clearly one has to ask what the basis is for them being tiered.”
In May 2008, the MMS and five individual physicians filed a lawsuit against the GIC and two health plans that take part in the GIC program — Tufts Health Plan and UniCare. The suit claims that the tiering program defrauds consumers and defames physicians. In December, a Superior Court judge heard arguments from the defendants to dismiss the suit. As this issue of Vital Signs went to press, the judge’s decision on whether the suit should proceed had not been handed down.
“News to Us”
In a message to state employees contained in the winter issue of its newsletter, For Your Benefit, the GIC maintained that it “continues to work with physicians in and out of our health plans to refine physician scoring methodology.”
“That would come as news to us,” Dr. Auerbach said. “I haven’t seen anything that indicates any substantial change in the methodology and I haven’t been hearing from physicians that there is a change.”
In the newsletter, the GIC also said that for the 2010 fiscal year, beginning July 1, it “will be using an advanced statistical model developed by a leading biostatistician at Johns Hopkins University that increases the probability that the quality scores are an accurate reflection of physician performance.” Physicians are skeptical that the GIC’s quality rankings next February will be any more accurate than they have been.
No Roadmap for Quality Improvement
Elaine Kirshenbaum, MMS vice president for policy, planning, and member services, said she has heard from many physicians that data used to rank them is difficult to understand and use to improve their quality performance. “If the information doesn’t help physicians to understand what’s going on quality-wise, the usefulness to the practice is limited at best,” she said.
Further, Kirshenbaum said, some specialties now being tiered under the GIC program do not have enough quality measures for statistical reliability, so these doctors are tiered only on efficiency. “If there’s no quality improvement component, these physicians are tiered based only on cost,” Kirshenbaum said.
In addition, last year the GIC mandated that its participating health plans assign no more than 20 percent of doctors to tier 1, 65 percent to tier 2, and 15 percent to tier 3. Kirshenbaum says these arbitrary cutoffs continue to “create a situation that could easily disrupt patient-physician relationships.”
Dr. Nutt feels badly that her new tier ranking will mean higher copayments for her patients at the Neponset Health Center. “They are already straining with the current copay,” she said. “It’s just so discouraging — you work hard to do the right thing. I don’t see anything they’ve done here that will improve my quality or cost.”
Still, Dr. Nutt said, “I love my work. I’m happy with what I do. But this is just wrong. There is no justice. It needs to be fixed.”
– Tom Walsh
Tuesday, April 15, 2008
6-3 Book Clubs
Welcome to our book club blog. This is a space where you can talk about your reading. As you know we have a lot of books to talk about. Sometimes, I will write a question that I want you to write about. But, most importantly, add your questions and ideas. Your thoughts are the most important part of this blog...so let's start blogging!
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