The Tufts Medical Center/Blue Cross Blue Shield Debacle

This past Monday, January 5th, 2009, I heard with interest Tufts Medical Center would no longer accept Blue Cross Blue Shield as medical insurance because negotiations had broken down regarding reimbursement rates. Among the plethora of things I am interested in are medicine, insurance and negotiations so this whole story is right up my alley. I’ve also been employed in positions that have involved some or all of these subjects at one time or another. I am not a stranger to the health care system (though, thankfully, usually not as a patient), insurance, medical coding and billing and negotiations both independently and with health care facilities.

I understand there are always two sides to every story so I was prepared to find Tufts asking for an unreasonable increase in reimbursements but when I looked into it further I was shocked, dismayed and then impressed that Tufts Medical Center has even been able to survive in the health care climate in Massachusetts. The odds have been heavily stacked against them.

In 1993 Massachusetts General Hospital and Brigham & Women’s Hospital agreed to join forces for the sake of efficiency. Or so they said at the time but having not actually merged, there was no discernible increase in efficiency. This merger was the birth of Partner’s HealthCare. Over time Partner’s absorbed Faulkner Hospital, McLean Hospital, Newton Wellesley Hospital, North Shore Medical Center, Shaughnessy-Kaplan Rehabilitation Hospital and Spaulding Rehabilitation Hospital. They also spawned Rehabilitation Hospital of The Cape and the Islands.

The piece de resistance occurred in 2000 when Dr. Samuel O. Their of Partners and William C. Van Faasen of Blue Cross Blue Shield of Massachusetts brokered a gentlemen’s agreement to increase both the cost of health care and the reimbursements from insurance. Since 2000 Blue Cross Blue Shield of Massachusetts has increased the amount it pays Partners Health Care by 75 percent. Partners also pressured Tufts health insurance and Harvard Pilgrim Health Care to provide similar increases. What started as a merger to increase efficiency and lower costs has grown into a huge capitalist venture between an insurance corporation and a health care ”non-profit” organization.

When arguing against agreeing to Tufts Medical Center’s nine percent reimbursement increase request Blue Cross Blue Shield points out that Tufts is not as formidable as facilities such as Massachusetts General or Brigham & Women’s but the irony is that Blue Cross Blue Shield colluded to make them that way. Blue Cross Blue Shield’s argument is not even much of an argument when you consider Tufts has one of the largest heart transplant centers in the area, gives exceptional service to patients who are, on a whole, sicker than those in other facilities and trains more primary care physicians than any other hospital.

The Boston Globe obtained rate information from Blue Cross Blue Shield of Massachusetts showing that Tufts Medical Center is paid 35 percent less than both Brigham & Women’s Hospital and Massachusetts General Hospital and 19 percent less than Beth Israel Deaconess. Lest you think this difference is because Tufts is a teaching hospital, all three of those facilities are teaching hospitals for Harvard Medical School.

From all my reading on this matter I have reached one major conclusion: Partners HealthCare and Blue Cross Blue Shield of Massachusetts started this avalanche that is now our nation’s health care crisis. Hand in hand, Partners has increased the cost of treatment while Blue Cross Blue Shield of Massachusetts has caused a raise in premiums from every insurer in order to keep up the pace of paying for it. My conclusion is only an opinion but if you start reading up on this, I think you are likely to draw the same conclusion.

As a nation, we need to work to find a solution to this crisis. We need to find a way to decrease the bureaucracy and paper work for our doctors and nurses so they can do what they do best – save lives. In the interim, until there is a solution, Blue Cross Blue Shield needs to treat Tufts Medical Center by the same standards as they treat other comparable facilities. Blue Cross Blue Shield needs to get back in the business of assuring access to quality health care rather than creating monopolies. You can afford it, Blue Cross Blue Shield. Show Tufts the money.