Boston Medical cited for poaching patients

By Alice Dembner, Globe Staff

The largest insurer of patients in the state's new subsidized coverage plan faces sanctions and a possible investigation by the attorney general for attempting to poach patients from other insurers.

Boston Medical Center sowed confusion when it sent a letter a month ago to 2,600 patients that wrongly implied they could only get care at BMC if they signed up for the hospital's insurance plan, called HealthNet. "To continue getting your care at Boston Medical Center, now is the time to switch..." the letter said.

The content of the letter and the direct approach to patients enrolled with other insurers violated HealthNet's state contract, according to the Commonwealth Health Insurance Connector, which oversees the state plan.

Both Boston Medical Center and the state are now recontacting patients to ensure they have accurate information about access to care and their choice of health insurers, which also include Network Health, Neighborhood Health Plan and Fallon Community Health Plan.

All the plans cover emergency care at BMC, and Neighborhood Health Plan and HealthNet cover some elective care there as well. BMC has declined to contract with Network Health, so people who enroll in Network Health cannot get their bills paid for non-emergency care at BMC.

HealthNet's executive director, Jean Haynes, yesterday issued a public apology and said the letter was aimed at ensuring continuity of care.

"Both Boston Medical Center HealthNet Plan and Boston Medical Center are deeply sorry for any confusion this incident has caused to Commonwealth Care members," she said in a statement (see below for her full response to the connector). "Both the health plan and the hospital are implementing procedures to avoid a repeat of such an occurrence."

The state will penalize HealthNet by reducing the number of patients it covers, according to a letter to HealthNet.

And the penalties could grow more severe. Attorney General Martha Coakley's office is reviewing HealthNet's actions to determine if the insurer violated state consumer protection law, according to a spokeswoman for Coakley. The state has also notified the federal government, which helps fund the subsidized insurance plan.

The misstep by HealthNet came as four insurers are jockeying for members. The insurers together cover more than 135,000 people enrolled in Commonwealth Care, part of the state's landmark initiative to ensure health coverage for nearly all residents.

The insurers have covered thousands of people in the state Medicaid program for years, but rarely competed head-to-head. For Commonwealth Care, the state sought competitive bids from the insurers to lower the cost.

Low-income patients who qualify for Commonwealth Care may choose one of the four insurers. If they don't choose, they are automatically assigned to the lowest-cost plans. In the Boston area, Network Health, which is affiliated with Cambridge Health Alliance, got the lion's share of the auto-assigned patients, including many who got care at BMC under the state's "free care" program. All patients are being allowed to switch plans during the month ending Dec. 15.

During open enrollment, the state allowed insurers to mass-market their plans and to contact their own members, but not to solicit directly members of other insurers. But HealthNet sent letters to 1,400 Network Health members and 1,200 Neighborhood Health Plan members who previously received care at BMC.

"BMC has been trying to keep hold of their patients," said Bill Walczak, chief executive officer of Codman Square Health Center, which is affiliated with BMC, but cares for patients from other insurers as well. But he said the competition among insurers has not helped patients, many of whom are unfamiliar with the ins and outs of insurance.

"The downside of competition is that it’s all about money and not about health," he said.

The letter went to one patient of the South End Community Health Center who doesn't speak English and regularly sees a specialist at Boston Medical Center. She is insured by Neighborhood Health Plan. Confused, she sent her daughter to the community health center to get answers.

"People are perfectly able to switch if they so desire," said Tristram Blake, executive director of the South End center. "But if it’s a veiled threat, it’s a different thing. They’re confused and they’re afraid that something will happen that will affect their care."

Officials of both Network Health and Neighborhood Health Plan declined to comment on HealthNet's actions. They said they were confident their plans would gain members through their comprehensive care networks.

The state is urging Boston Medical Center to sign a contract with HealthNet as one of the remedies.

Said connector spokesman Richard Powers: "The landmark Massachusetts healthcare initiative is for the benefit of hundreds of thousands of citizens who would otherwise be uninsured. In this instance, BMC seems to have lost sight of this. We’re extremely disappointed that BMC would undertake such a misleading and confusing marketing effort."

Haynes' letter to the connector:

December 3, 2007

Mr. Jon Kingsdale
Executive Director
Commonwealth Health Insurance Connector Authority
100 City Hall Plaza, 6th Floor
Boston, MA 02108

Re: Corrective Action Plan

Dear Mr. Kingsdale:

This is in response to the Commonwealth Health Insurance Connector Authority’s (the Connector) letter received by Boston Medical Center HealthNet Plan (BMCHP) on November 30, 2007. The Connector’s letter cites certain deficiencies on the part of BMCHP with respect to marketing requirements in the agreement between BMCHP and the Connector, and requires BMCHP to take corrective actions.

BMCHP entered into an agreement with the Connector dated October 1, 2006 under which BMCHP offers Commonwealth Care to eligible Massachusetts residents. Commonwealth Care is an insurance program operated by the Connector pursuant to M.G.L. Ch. 118H to provide health insurance to uninsured persons who satisfy specific income and eligibility guidelines. Commonwealth Care plans are offered by the following four Massachusetts Medicaid managed care plans: BMCHP, Fallon Health Plan, Network Health and Neighborhood Health Plan (NHP).

On October 31 and November 1, 2007, Boston Medical Center (BMC), a contracted provider in BMCHP’s provider network, sent a notice to certain BMC patients enrolled in Commonwealth Care. The patient notice was intended to ensure continuity of care between Commonwealth Care patients and their BMC providers. BMC is not a participating provider with Network Health, and BMC and NHP have a contract that covers most services except primary care. The patient notice at issue was sent to BMC patients enrolled in Commonwealth Care through Network Health and Neighborhood Health Plan (NHP). It advised such members that during open enrollment they could switch to BMCHP in order to continue seeing their BMC provider. While the intent of the notice was to facilitate uninterrupted patient care, BMCHP now recognizes that the patient notice constituted a “marketing material” as broadly defined in the agreement between BMCHP and the Connector. BMCHP also recognizes that the agreement between BMCHP and the Connector obligates BMCHP to hold its contracted providers to substantially all of the marketing requirements set forth in the agreement between BMCHP and the Connector. As such, BMCHP should have obtained Connector approval for the patient notice sent to Commonwealth Care members in this case.

BMCHP regrets any deficiencies in complying with its contract marketing requirements. Most importantly, we regret any confusion caused to Commonwealth Care members as a result of this notice. BMCHP is committed to the success of Commonwealth Care and to working with the Connector to ensure the same. We are proud to have supported and collaborated on the legislation that resulted in Chapter 58 of the Acts of 2006, and share with the Connector the mission of providing high quality, affordable insurance to uninsured Massachusetts residents. BMCHP is committed to working with the Connector to implement the required corrective action plan, and will take the necessary steps to prevent any similar occurrence.

Since becoming aware of this situation, BMCHP has launched an internal investigation to review the matter, and has developed a plan by which BMC communications to Commonwealth Care members must be reviewed by counsel for both BMC and BMCHP prior to distribution. We have contacted certain community health centers to determine if they have had any communications with members about open enrollment. We have reached out to executives at both Network Health and NHP to apologize for this matter. We have and will continue to work with the Connector to take the appropriate corrective steps. While acknowledging our responsibility to comply with the applicable marketing requirements, we do note for the record that the harm, if any, to consumers as a result of this situation was limited to potential questions about receiving care outside of a health plan’s contracted network. At no time was a patient denied access to care or coverage, nothing in the notice stated or implied that a patient would lose or become ineligible for continued coverage under Commonwealth Care, and no patient suffered any economic loss as a result of the notice. Nonetheless, we recognize that the patient communication did not comply with the contract marketing requirements, and are taking the appropriate measures internally and with the Connector to correct this matter.

Corrective Actions

Following are the specific corrective being required and the remedial steps being implemented by the Connector, and BMCHP’s response to each:

1) The Connector requires that BMCHP take the following Corrective Actions to remedy this situation:

a) BMCHP, following discussions with Connector representatives, already provided lists of the contacted individuals to Network Health and Neighborhood Health Plan. BMCHP, in addition, must ensure that BMC sends out, by 5 pm on Monday, December 3, retraction letters to all members of either Network Health or Neighborhood Health Plan who received the marketing letter. Copies of the letters that we require BMC to send out are attached. The retraction letters must be signed by a senior official of Boston Medical Center.

BMCHP is working with the Connector and BMC to send the required retraction letter by 5:00 PM on Monday, December 3, 2007 to all members who received the original patient notice. As you are aware, when we received the proposed remediation letter on November 30, 2007, we voiced concerns that the remediation letters should inform Commonwealth Care members that Network Health does not have an agreement with BMC and that NHP’s agreement with BMC does not include primary care. We suggested that the remediation letter disclose any referral and authorization requirements for Network Health and NHP members seeing out-of-network providers. We received final templates from the Connector today shortly after 11:00 AM. As you are aware, the Connector determined that such disclosures were not necessary.

We have sent the templates to BMC for processing and mailing, and are working on satisfying the 5:00 PM, Monday, December 3rd mailing deadline. The remediation letters are being signed by Ronald Bartlett, Chief Financial Officer for BMC.

b) BMCHP must provide by December 5, 2007 a description of how the BMC marketing letter was planned and distributed, who was involved, and what information the involved individuals from BMC used to create the lists of members who received the letter. The description should also indicate whether any community health centers were involved in this marketing effort and whether any more letters went out than those identified above. BMCHP must then describe the specific actions it intends to take to ensure that unauthorized marketing materials are not sent out by BMCHP or by their Network Providers. BMCHP must propose these specific actions to the Connector in writing. A senior official of BMCHP must certify that the outlined specific actions will be put into place and must, within 90 days, provide a report on whether the specific actions have been implemented.

In October, BMCHP staff reached out to providers1, including BMC, to inform them of the Commonwealth Care Open Enrollment period from November 1 to December 15 2007. BMCHP staff educated providers about Open Enrollment and offered to help to facilitate patient health plan changes. BMCHP informed providers that Open Enrollment was a legitimate opportunity for a provider’s patients to change health plans, if the one they were currently in was not one that providers accepted.

BMC Activities
· On September 13, a CareNet staff member, contacted BMC Patient Financial Services (PFS), requesting a meeting to discuss Commonwealth Care Open Enrollment.
· On October 2, this CareNet staff member and a BMCHP employee met with BMC PFC to discuss Open Enrollment. BMC expressed its hope that Open Enrollment presented the opportunity for BMC patients who had been assigned to Network Health to switch to BMCHP. BMCHP offered assistance in drafting a letter and BMCHP marketing staff drafted a letter.
· On October 9th, BMCHP sent a draft letter to BMC PFS for BMC Patients belonging to Network Health.
· This BMCHP draft was revised and approved by BMC PFS staff and the same letter was created for BMC patients belonging to NHP.
· BMC PFS programmed the letters into BMC’s patient registration system and the letters were printed on October 28. During the week of October 29th letters were sent to patients whose names appeared in the BMC patient registration system.

Health Center 1 (HC1) Activities
· BMCHP staff met with HC1 staff on October 25th at their request. HC1was clear that it has contracts with both BMCHP and NHP and they wanted their patients to know that they had the choice of those two plans.
· HC1 drafted its own letter, which BMCHP first saw on December 3rd, when a copy was faxed to the Plan.

Health Center 2 (HC2) Activities
· HC2 developed its own strategy to contact patients in response to a number of coverage issues; including Commonwealth Care.
· HC2 drafted its own letter informing their patients of the two types of Plan coverage that it accepted: BMCHP and NHP. HC2’s communication also noted that if their patients received services at MGH, they would need to select NHP because BMCHP does not include MGH in its network.
· A copy of the HC2 letter was first seen by BMCHP on December 3rd, in response to its inquiry.

Copies of the notices described above are attached as Exhibit l. It is clear that these letters are comparable to the BMC patient notice at issue. It is also clear that there is a practice among providers of communicating with their patients. We think such communications are expected by patients. These communications are intended to support patient needs and may at different times benefit different health plans. In the cases described above, NHP and BMCHP may have gained Network Health members. However, the purpose of the provider communications is to support patient care and may involve important information on the terms or requirements of Commonwealth Care including open enrollment. We suggest that the focus should be on the value of information provided to patients as opposed to membership gains or losses among the health plans. We further question the practicality of holding health plans responsible for monitoring every communication between thousands of network providers and their patients. However, if this is the expectation, then the Connector must hold all health plans to the same standards.

As requested, BMCHP will provide the Connector a specific corrective action plan by December 5, 2007.

c) At the Connector’s option, representatives of BMCHP and BMC may be required to attend a meeting with representatives of Network Health and/or NHP to discuss these remedial efforts and related topics.

BMCHP, and BMC as appropriate, will be happy to meet with representatives of Network Health and/or NHP to discuss these remedial efforts, and first offered to do so on November 19, 2006. As noted above, BMCHP has reached out to executives at Network Health and NHP on this matter. Likewise, counsel for BMCHP and counsel for BMC each has contacted counsel for NHP on this matter

2) The Connector intends to take certain immediate actions to try to repair the damage that these marketing letters may have caused during the on-going open enrollment period. Connector personnel or Connector contractors have already begun contacting those members who have already indicated, during this open enrollment, that they wish to switch from either Network Health or Neighborhood Health Plan to BMC HealthNet. Connector personnel will make clear to those members that the letter contained misleading information. Connector personnel will ask if the member still wishes to change plans in light of this correct information and, if he or she does not, will reverse the plan change to BMCHP.

Further, going forward, representatives of Maximus, on behalf of the Connector, will ask any member expressing an interest in switching to BMCHP from either Network Health or Neighborhood Health Plan if he or she received the marketing letter and, if so, will explain to the member that the marketing letter contained inaccurate information. The Connector personnel will then ask the member if, in light of this corrected information, he or she still wishes to make the plan change.

BMCHP acknowledges that the Connector is taking the actions outlined above and has no objections. We do note for the record that the Connector’s remedial measures may have an impact that is greater than the original patient notice. It is our expectation that if it is determined that a member switched from Network Health or NHP to BMC for reasons independent of the patient notice that such member will not be coached or encouraged to switch out of BMCHP.

3) BMCHP or BMC must contact other providers, such as community health centers, who may have been effected by this marketing letter, to indicate that the marketing letter was inaccurate. Please include in the Corrective Action Plan the retraction letter BMC will send out, which will need to be approved by the Connector, and to whom BMC intends to send the letter.

Please see our response to item #1b above.

4) During the current open enrollment process, the Connector has seen some members move from Network Health and Neighborhood Health Plan to BMCHP. The open enrollment period will go on until December 15, 2007. As a result, there is some evidence that BMCHP has received some financial gain as a result of the improper marketing materials sent out by BMC. As a result, the Connector will make no adjustment to the auto-assignment logic that occurred for an October 1, 2007 effective date in the Boston area and will re-not assign to BMCHP any enrollees involved in that October auto-assignment, regardless of any claim that BMCHP may have that it was entitled to have a certain number of auto-assignments directed to it during the October auto-assignment. This decision will provide some financial redress to Network Health.

BMCHP does not object to the above described measures. However, we do note that Commonwealth Care members are entitled to switch plans upon open enrollment and may do so for a variety of reasons, chief among which may be provider access. Independent of the patient notice sent by BMC, members may have decided to switch from Network Health or NHP to BMC at open enrollment for any number of reasons, including access to providers, or recommendations from friends and family members.

BMCHP further notes there is no evidence to support the conclusion that BMCHP already has received “some financial gain” as a result of the BMC communication to Network Health and NHP members. Unless the Connector matches the population who received the patient notice at issue with the population who has switched from Network Health and NHP to BMCHP, it is premature to conclude that the patient notice had any impact. Further, without querying this population to understand (i) if the member actually received the letter at issue (this is important as it is well understood that demographic information for this population frequently is inaccurate), and (ii) if the letter actually impacted the member’s decision to switch health plans, it is impossible to judge that the BMC patient notice had any effect on a member’s decision to change health plans at open enrollment. We have asked the Connector for information on the number of members who have switched health plans during open enrollment, and for a breakdown of the numbers who specifically changed from Network Health or NHP to BMCHP. We also have asked about tracking this group against the group of members who received the original patient notice from BMC. It would be possible for Network Health, NHP and the Connector to work together on this simple analysis. Without such basic information about which members changed health plans during open enrollment and why they did so, we must take exception to the statement that the BMCHP has received any financial gain from this situation.

5) The Connector notes that members of Network Health are disadvantaged by the inappropriate marketing actions here because Boston Medical Center has, to date, refused to enter into a contract with Network Health. The Connector urges Boston Medical Center to enter into such a contract.

Although we think the Connector’s urging that BMC enter into a contract with Network Health is outside the scope of this matter, we have provided a copy of the Connector’s request for a corrective action plan to BMC.

6) The Connector may require additional actions by BMCHP to provide financial remedies for Neighborhood Health Plan.

As you are aware, BMCHP staff have had numerous conversations with Connector staff since becoming aware of this situation, and have discussed a variety of measures that may be appropriate in this situation. We will continue to work with the Connector on appropriate next steps.

7) BMCHP acknowledges that the Connector will be referring this matter to the Massachusetts Attorney General’s office as well as to Center for Medicare & Medicaid Services (CMS). We note that we have self reported this matter to the Attorney General’s office.

In closing, we would like to reiterate our sincere regret about any confusion caused by this matter, and our commitment to take the appropriate steps internally and with the Connector to correct this situation. If you have any questions or require additional information, please do not hesitate to contact me at 617-748-6176.

Very truly yours,

Jean Haynes
Executive Director