Insurance dispute puts access at risk

Thousands of South Shore Health patients could soon lose access to the system’s hospitals or physicians due to contract disputes with two different insurers.

The Weymouth-based health system has begun notifying patients who have Tufts Health Direct Plan and UnitedHealthcare Medicare Advantage that contract negotiations with the two insurers are in flux, potentially leading to patients losing access to the health system in the coming months. The dispute is the latest sign of escalating financial pressures on insurers and medical providers.

“South Shore Health is committed to providing high-quality, accessible, and affordable advanced care to our community," the health system said in a statement. “To remain financially stable and continue care locally, contract changes have been necessary."

The potential terminations differ depending on which insurer and what patients are trying to access. But for approximately 3,900 patients with a United Medicare Advantage plan, South Shore Hospital and South Shore VNA will become out of network starting Jan. 1. Doctors and providers at the medical center will be out of network starting in May, and urgent care services at the system’s Health Express clinics will be out of network in mid-October.

South Shore Health notified an additional 2,200 patients with Tufts Health Direct insurance that hospital and physician services may be out of network Jan. 1. Urgent care services will become out of network in September.

“If you are scheduled for care at South Shore Hospital, South Shore Medical Center, or a South Shore Health specialty practice after December 31, 2025, your appointments will be cancelled," the system said in a memo to Tufts patients posted on its website. “This includes scheduled surgical procedures, lab testing, well-visits, and radiology services."

Some patients may continue to receive care despite the contract termination, depending on insurer discretion, including access for 90 days for serious and complex conditions, people receiving inpatient care, care for those with a terminal illness, and pregnancy care up to six weeks postpartum.

Negotiations remain ongoing. Though it is unlikely the contract will resolve with United Medicare Advantage, the health system said it has extended its contract with UnitedHealthcare for employer-sponsored plans until February, and it is continuing to negotiate a new contract for those members.

In a statement, a United spokesperson said many of its other products and care with other providers was not affected. For example, South Shore providers are not currently in network for Medicare Advantage products, but Coastal Medical Associates providers are. The contract dispute also doesn’t affect Medicare supplemental plans.

“People enrolled in our network for Medicare Advantage plans continue to have access to a large network of providers throughout Massachusetts," the spokesperson said.

South Shore is also in active negotiations with Point32Health, the nonprofit parent organization of Tufts Health Plan and Harvard Pilgrim Health Plan.

“We have notified impacted members of the potential termination and how to select a new primary care provider or specialist if we are unable to reach an agreement," said a spokesperson for Point32Health. “Our members are our top priority, and our goal is to minimize any disruptions to their care."

The South Shore disputes come on the heels of a contentious battle between Blue Cross Blue Shield of Massachusetts and UMass Memorial Health, which narrowly avoided a contract termination that would have affected nearly 200,000 patients. A number of other contract terminations involving Medicare Advantage have occurred in recent months.

Experts say more such contract disputes are surely to come.

Providers feel increasingly squeezed due to federal changes to Medicaid and NIH funding, while struggling to pay for rising health care costs for their own employees. Meanwhile insurers are struggling under the weight of rising health care utilization and increased pharmaceutical and provider costs.

That context has set up an environment where health systems are asking for large increases in contract negotiations with insurers. Insurers, facing multimillion dollar losses themselves, have been reluctant to relent.

At a recent talk, Sarah Iselin, CEO of Blue Cross Blue Shield of Massachusetts, said nearly every contract negotiation of her three-year tenure has started with hospital systems asking for payment increases of 10 to 15 percent.

“That is the tension we’re going to navigate in the years ahead," she said. “How do we balance the consideration between what consumers and employers can afford with the reality of the costs that those hospital systems — that are themselves running businesses — are experiencing?"

Jessica Bartlett can be reached at [email protected]. Follow her @ByJessBartlett.