Each Patient Counts: Massachusetts Medical Society Weblog

Connector Board Cuts Some Payments for 2008

The MMS is dismayed by the Commonwealth Connector Authority’s reported decision to require insurers who bid on insurance products offered by the connector to cut provider payments next year by 3 to 5 percent. The reductions, voted on Thursday (Dec. 13), will be included in bid documents that will be issued early in 2008.

Authority members implemented the mandated provider cuts in contracts of insurers who bid to provide services to the public through the connector in order to reduce projected increases of 14 percent in payments to insurers.

The intent seems to be to lower the current fee schedules which attracted providers to the managed care contracts by providing significantly higher rates than Medicaid. New participating providers were necessary to allow the plans to have any chance of providing access to care to the thousands of new subscribers anticipated under the new law. The managed care plan rates apply both to Medicaid eligible patients and those who purchase or otherwise receive insurance coverage through the Connector.

The cuts would apply to the four Medicaid managed care health plans who also provide care to insureds. They do not apply to Medicaid fee-for-service plans, which by prior legislative requirements are scheduled to rise another $17-$19 million next year.

Until recently, the four managed care plans had offered a fee schedule above Medicaid indemnity rates for services provided to Medicaid and individuals insured through the Connector. Patrick Holland, the authority's chief financial officer, was quoted in news reports stating, “There's no justification to be paying more than Medicaid rates."

The managed care plans generally receive capitated payments from Medicaid and the Connector. Thus the costs of fees are not directly paid by the state in most cases and a 3 to 5% cut to providers may not result in direct savings to the state.

The MMS noted that the Authority’s decision will adversely impact patient access and physician practice viability, and runs counter to the Legislature’s investment and commitment to support providers who have supported expanding access to care.

These cuts, demanded by the Connector, seem poorly considered at a time when significant questions are being raised about the ability of the four plans in question to develop and maintain an adequate provider network to cover a significant increase in insured patients, their traditional Medicaid clients and expanded Medicaid populations.

Public Health Council postpones vote on limited service clinics

After nearly 90 minutes of discussion on a wide range of issues, the state Public Health Council today tabled a vote on new proposed regulations governing "limited service clinics" in drug stores and other retail establishments. The Council will now vote at its January meeting at the earliest, after amendments have been added to the regulations and selected proposed regulations have been revised.

The 13-members of the newly re-constituted Public Health Council engaged in vigorous discussion about topics that focused on quality of care and public health and safety. The public health expertise and experience of the panel greatly contributed to the quality of the debate.

Among the specific issues raising questions were the capabilities and training of on-site staff to adequately address the differences between adult care and pediatric care; the conflict engendered by the sale of tobacco products in a healthcare environment; the location of toilet facilities and waiting room areas, away from the normal retail consumer traffic; the availability of back-up and follow-up care and interpreter services if needed by the patient; how referrals to additional care would be addressed; and how the Public Health Council and Department of Public Health would handle violations of regulations. 

"The focus of today's discussion," said Bruce Auerbach, M.D., President-Elect of the Massachusetts Medical Society, "clearly demonstrated the Council's deep concerns about limited service clinics in the areas of quality of care, ensuring the public’s health through sanitation and infection control, potential conflicts of interest and patient safety. The Council is to be commended for its thoughtful approach to public health policy." 

Dr. Auerbach said that the Council pinpointed some of the same issues that have been raised by physicians, hospitals, and community health centers regarding limited service clinics. 

The revised regulations presented today to the Council followed two public hearings and a public comment period in which some 50 individuals and organizations offered testimony and comment. 

DPH Commissioner John Auerbach chaired the meeting of the council and presided over the discussion. The Commissioner identified ten specific areas for further amendments to be developed prior to next month’s vote on a revised set of proposed regulations. The identified areas were:

1. Potential conflicts of interest in siting clinics in pharmacies.
2. Requirements for a more distinct waiting area to address infection control and patient privacy.
3. Whether clinics should be prohibited in stores selling tobacco or whether a disclosure posting on health impacts would suffice.
4. Services involving disrobing were prohibited but this may need further definition.
5. Adequate credentialing of practitioners and supervising physicians must be guaranteed to ensure competence of those serving pediatric and adult populations.
6. Location of toilet and janitor facilities must be more specific.
7. Hand sanitizers may be mandated, ( The new version mandates handwashing facilities specific to examination rooms.)
8. The role of the Public Health Council in reviewing complaints and license actions will be revisited.
9. The issue of referrals of patients with needs beyond those the clinic may meet and the question of payment when services may be duplicated will be addressed.
10. Systems of quality evaluation may be mandated.