Medicolegal Issues

Massachusetts Effect


With the first major statewide attempt at universal healthcare access under way in Massachusetts, everyone from presidential candidates to uninsured families on the other side of the U.S. is watching to see if the state’s plan will succeed. If so, it could become the basis of a national healthcare plan.

Massachusetts healthcare reform became law April 2006 as part of the Act Providing Access to Affordable, Quality, Accountable Health Care. It requires that virtually all state residents either purchase health insurance or get coverage through state-sponsored insurance for people with low incomes (May 2007 The Hospitalist, p. 1). The plan, based on insurance market reforms, merges the individual and small-group insurance market, allowing residents to get lower group insurance rates.

Policy Points

Care Costs Continue to Climb

The cost of health insurance is on the rise, according to a survey by the Kaiser Family Foundation. Premiums paid by U.S. workers and their employers increased by an average of 6.1% this year, outpacing inflation and pay raises.

Premiums for the average American family with employer-sponsored health insurance surpassed $12,000—with employees paying approximately one-fourth of that cost.

The survey predicts health insurance costs will continue to increase in 2008. A large number of the more than 3,000 companies surveyed indicate they plan significant changes to their health plans and benefits. Nearly half say they are very or somewhat likely to raise premiums.

San Francisco Offers Universal Care

San Francisco has implemented the Healthy San Francisco program, which guarantees free or sliding-scale healthcare to uninsured adults. Since September, city residents have been able to go to a “medical home”—a specific city clinic—and receive medical treatment and referrals. The goal is to steer the uninsured away from emergency department (ED) visits and toward preventive care.

The program, estimated to cost $200 million, is funded with the help of state and federal money, patients’ fees, and employer contributions.

Until November, enrollment in the program was limited to adults with incomes at or below the federal poverty level.

Emergency Assistance

A Senate bill would improve access to emergency medical services and the quality and efficiency of care furnished in EDs of hospitals and critical access hospitals.

S.B. 1003, an amendment to title XVIII of the Social Security Act, would advise Congress on federal programs, policies, and financing needed to ensure the availability of effective delivery of screening and stabilization services in hospital EDs, including the coordination of state, local, and federal programs for responding to disasters and emergencies.—JJ

The law required coverage by July 1, and residents must show evidence of their coverage on their income tax return or face a substantial fine—up to 50% of the cost of a health insurance plan.

Many Massachusetts residents get healthcare coverage through their employers. The state plan requires companies with more than 10 employees to provide coverage or to pay a “Fair Share” contribution of up to $295 for each employee each year. Employers must also offer a “cafeteria plan” that allows workers to purchase healthcare with pre-tax income.

The bill created the Commonwealth Health Insurance Connector, which offers affordable, quality insurance to individuals and small businesses. The Connector board approved plans offered by seven insurers that include several options.

As for low-income residents, sliding-scale government-funded subsidies are provided by the Commonwealth Care Health Insurance Program (C-CHIP). As of June 1, nearly 80,000 low-income adults had enrolled in C-CHIP. In addition, the statute expanded MassHealth (Medicaid and SCHIP) coverage for children of low-income parents and restored MassHealth benefits such as dental and vision care.

The plan also includes a system for quality standards and for publicizing performance of providers.

The money for the plan comes from several sources. Gov. Deval Patrick has requested $1.725 billion to fund the program in the next fiscal year. This will supplement federal Medicaid payments, employer contributions, and general revenues.

What Hospitalists Face

How will universal healthcare coverage for state residents affect Massachusetts hospitalists and other physicians? Massachusetts resident Win Whitcomb, MD, director of clinical performance improvement at Mercy Medical Center in Springfield, and co-founder of SHM, weighed the pros and cons.

“The first issue is the effect on primary care providers,” says Dr. Whitcomb. “A large number of patients will be steered into the system of primary care, which is already overwhelmed. A new [state] commission has been formed to address this shortage, but it’s too late—the system already lacks capacity.”

Soon-to-be-overwhelmed primary care physicians will take every step possible to share the workload: “I think [the plan] will be a new impetus for primary care providers to refer patients to hospitalists,” stresses Dr. Whitcomb. “Hospitalists may well see new demand from primary care providers.”

Will this trend mean more openings for hospitalists at Mass­achusetts institutions? “There are so many drivers behind [the growth of the hospital medicine]; this is just another driver,” says Dr. Whitcomb.

The second likely outcome of the plan will be a transformation of the types of patients treated by hospitalists. Hospitalists around the country are well aware of the problems of treating today’s uninsured patients. “The uninsured tend to show up in the ER in the middle of the night, with diseases in an advanced state” because they haven’t seen a doctor until the last minute, says Dr. Whitcomb. “That situation is not going to go away, but it might decrease” in Massachusetts under the new plan.

“The big question is, will the previously uninsured population, which hospitalists are all too familiar with, be a fundamentally different population?” muses Dr. Whitcomb. “In other words, if [patients] go through a primary care provider and have good management of their illness, will they become a different type of patient than hospitalists are seeing at present? This would be good for hospitalists; it will mean more control over chronic disease and illness.”

The big question is, will the previously uninsured population, which hospitalists are all too familiar with, be a fundamentally different population.

—Win Whitcomb, MD, director of clinical performance improvement at Mercy Medical Center in Springfield, Mass., and co-founder of SHM

How Is It Working?

The plan is still in its infancy, but more than 150,000 of the state’s previously uninsured residents had coverage before the July deadline. However, the total estimated number of remaining uninsured is 250,000 to 375,000.

“The two roadblocks are the ability to enroll patients and finding primary care to handle everyone,” says Dr. Whitcomb. “It’s just one of those wait-and-see issues. I applaud the plan. It’s a sincere effort to deal with the uninsured. I think the primary care shortage is a major problem and will impact the success of the plan.”

Hospitalists around the country may want to keep an eye on developments in Massachusetts because the state’s healthcare system could affect their patient loads, daily work, and compensation. TH

Jane Jerrard has been writing for The Hospitalist since 2005.

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