The first for-profit insurance company approved to offer government-subsidized coverage under Massachusetts' health reform has dangerously restricted access to primary care, according to data reported in Thursday's New England Journal of Medicine. Researchers say the findings raise troubling concerns about the Obama administration's new health law, which is modeled after the Massachusetts plan.
Three Harvard-affiliated physicians report that out of a list of 326 doctors identified as members of the provider network of CeltiCare, a for-profit insurer contracted by the state of Massachusetts to take over coverage of about 30,000 legal immigrants (and, more recently, low-income citizens), only 217 were non-duplicate adult primary care providers. Of these 217 doctors, 25 percent could not be reached by telephone.
Of those primary care doctors who were reachable by telephone, only 37 percent, or 60 providers, said they were accepting new CeltiCare patients. In those cases, the average wait time for an appointment was 33 days, even though the patient was described as having a chronic illness like diabetes or hypertension.
Moreover, although many of the patients who had been forced into the CeltiCare plan don't speak English, only 38 of the doctors who were accepting new patients had any form of translation services.
The plan's failure to provide adequate access to doctors for its members raises grave concerns not only about Massachusetts' reform, but also about the recently enacted national reform, the researchers say. The national plan closely mirrors Massachusetts' reform, but relies far more heavily on for-profit insurers.
The report points out that even when patients have insurance, profit-driven plans may discourage them from getting the care they need by "rationing by inconvenience."
The data appears in a letter titled "Immigrants' experience with publicly funded private health insurance" in the Aug. 5 print edition of the journal. It was written by two resident physicians at the Harvard-affiliated Cambridge Health Alliance and a Harvard Medical School faculty adviser, and is based on the work of a group of interns, residents and medical students from several Boston-area hospitals and medical schools.
These doctors-in-training carried out the research after they became worried when some of their sickest patients - patients with cancer, diabetes and other severe health problems - were forced from their existing insurance plan into the CeltiCare plan. They then were told that they could no longer be treated at many of their previous health clinics, forcing them to find new doctors.
The researchers identified doctors available to the CeltiCare patients using the plan's "Find a Provider" website. They called each of the doctors' offices within a 5-mile radius of their hospital, identifying themselves as relatives of a chronically ill, older adult who needed an appointment soon. If an appointment was offered, the researcher asked about the availability of translators.
"Trying to get an appointment was even more daunting than these numbers suggest," said Dr. Cassie Frank, a co-author of the article. "Many clinics forced me to call several times to get an appointment. One said they only open up appointments on Monday morning, and that to have a chance of getting any appointment slot I'd have to show up an hour before the clinic opened to be first in line."
Dr. Malgorzata Dawiskiba, another co-author, said: "The state suddenly shifted thousands of sick patients to a cut-rate plan. But instead of getting a bargain, the patients were left stranded - insured, but unable to find a doctor who could care for them. These were people whom we knew. We and our supervisors had been their doctors, sometimes for many years, and overnight they were told 'you can't come here anymore.'"
Dr. Ruth Hertzman-Miller, an instructor at Harvard Medical School and study co-author, commented: "The problems faced by CeltiCare's patients may soon become much more widespread. Our legislative leaders want to require every insurer in Massachusetts to offer a plan with a restricted list of doctors and a lower price tag. But that kind of restricted coverage may be little more than a worthless piece of paper."
"Immigrants' experience with publicly funded private health insurance," Ruth Hertzman-Miller, M.D., M.P.H.; Malgorzata Dawiskiba, M.D.; Cassie Frank, M.D. New England Journal of Medicine, Aug. 5, 2010.