Deal or no deal? Thousands may lose coverage at St. Vincent, MetroWest hospitals

As the clock ticks down on 2024, thousands of people are slated to lose in-network health insurance coverage at two major Central Massachusetts hospitals — unless a last-minute deal is made.

Due to months of unsuccessful contract negotiations, Point32Health is scheduled to end in-network coverage for 17,000 members at Saint Vincent Hospital in Worcester and MetroWest Medical Center in Framingham and Natick as of Jan. 1.

If an agreement isn’t reached in the final hours of the year, the hospitals, owned by for-profit Tenet Healthcare Corp., will join two others in contract impasses with Point32Health, the state’s second-largest insurer, which owns Tufts Health and Harvard Pilgrim Health.

UMass Memorial Health and Boston Children’s Hospital already announced they could not reach a new contract for Jan. 1 with Point32Health for Tufts Health Direct members specifically.

The change at Tenet hospitals would affect any Point32Health member: Tufts, Harvard Pilgrim, employer-sponsored plans and those through Medicaid and Medicare.

Between all four hospitals/health systems, upwards of 40,000 patients statewide could be affected by the breakdown in contract negotiations.

Point32Health continuity of care

A spokesperson for Point32Health told MassLive Monday that if they fail to negotiate a contract by New Year’s Day and “Tenet refuses to extend the deadline,” the insurer will move forward with its continuity of care guidelines.

That means existing members could still receive services at in-network coverage levels “for specified medical and behavioral services” for a certain period of time.

As the not-for-profit insurer struggled to strike deals with major hospitals across the state this year, Point32Health proposed a $165 million spend to purchase Health New England, a health plan that offers insurance for 180,000 members in Western Massachusetts — while also reporting an operating loss.

State regulators approved the purchase of Health New England in October, and as of early December, the sale was reaching finality but hadn’t closed yet.

Meanwhile, in August, Point32Health reported an operating loss of $155 million for the first six months of 2024, citing “elevated health care costs driven by increased utilization for services in pharmacy, including GLP-1 weight loss drugs, acute and post-acute inpatient admittance and residential treatments for substance use disorder.”

St. Vincent: Point32Health is ‘prioritizing profits’

Saint Vincent Hospital did not respond to a request for comment Monday.

But in a statement on the hospital’s website, Tenet tells patients the coverage change will “disrupt trusted physician-patient relationships and place undue financial burdens on families as they could face significantly higher out-of-network costs or go to a higher cost facility.”

Their options, essentially, are to find different providers who are covered or select a new health plan entirely. The open enrollment period for the Massachusetts Health Connector runs through Jan. 23, 2025.

Tenet also pointed a hard finger at Point32Health, saying the insurer “is not engaging in good faith discussions to reach an equitable agreement.”

“Point32Health leadership is prioritizing their profits over their Massachusetts members’ network adequacy,” Tenet said. “Point32Health continues to cite their operating loss for the reason for unfair reimbursement despite the fact they continue to increase premiums (the cost to you).”

Tenet said Point32Health plans already reimburse Saint Vincent Hospital and MetroWest Medical Center “well below the average payment to peer Massachusetts hospitals,” specifically 10% and 20% less, respectively.

What Point32Health says

Point32Health tells a different story — that hospitals are demanding unreasonable reimbursement rates.

In November, it released a detailed statement essentially rebuking claims made by Tenet, saying the Dallas-based hospital owner “published inaccurate messaging about our negotiations and we need to set the record straight.”

“It is unfortunate Tenet has decided to put you in the middle of this negotiation as a bargaining chip,” it wrote to members.

Point32Health said Tenet has “demanded” payments over the next four years significantly above the state Health Policy Commission’s cost growth benchmark.

The Telegram & Gazette previously reported that Tenet sought reimbursement increases of 30.55% over four years for commercial plans and 26% over four years for qualified health plan members, according to Point32Health.

“Further, Tenet included in its latest contract proposal a clause that could restrict health care access for many people in Worcester and surrounding communities,” the insurer said, not specifying the contents of the clause.

In a statement to MassLive Monday, a spokesperson said, “Provider-rate demands directly contribute to higher premium rates for everyone.”

All the insurer would say about its pending Health New England deal was that the purchase hasn’t closed.

Point32Health has clarified that its negotiations with Tenet are specific to the Saint Vincent Hospital and MetroWest Medical Center facilities — not doctors affiliated with the hospitals, as is the case with UMass Memorial Health and Boston Children’s Hospital.

“Even if an agreement is not reached, members may continue to see their primary care providers and specialists at other points of care, and still visit Tenet Healthcare’s emergency departments,” the insurer said.

‘Trying to exert as much pressure as we can’

Local officials and community members have been ringing the alarm for months, contacting the state’s Division of Insurance and Eileen Auen, interim board chair at Point32Health.

State Rep. Jim O’Day, D-14th Worcester, said he’s “written letters to everyone who will listen.”

“Worcester used to have five hospitals, now we have two,” O’Day said. “How can we have a city of 200,000 people with two hospitals and not have either of them accept one of the major insurances?”

O’Day said he and several of his colleagues on Beacon Hill have been watching the evolving situation closely, “trying to exert as much pressure as we can.”

“My frustration has been that I haven’t yet been able to determine who can really apply the big-time pressure on both of these entities,” he said. “As responsive as the Division of Insurance has been, they are not the final arbitrator of this at all. I don’t know who is. I guess because of the free market, no one really is.”

If nothing else comes from the contract breakdown, O’Day hopes patients in the future will at least be provided a “longer runway” in terms of notification when a potential loss of coverage is looming. Currently, it’s 90 days.

“That’s not enough time,” he said.

What patients can do?

Tenet patients affected by the possible change still have time to select a different health insurance plan for 2025 through the Massachusetts Health Connector. Open enrollment runs through Jan. 23.

The Health Connector offers health and dental plans for individuals, families and small businesses through major health and dental insurance providers.

If patients choose to stay with Point32Health plans and the entities don’t reach an agreement, they will likely be forced to find care elsewhere unless they want to pay out-of-network costs at Saint Vincent and MetroWest Medical Center.

For more information, visit www.mahealthconnector.org.

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