“It will have penalties that I feel ought to concern all the native payers”
BOSTON, JAN. 30, 2025…..Confronting hovering well being care prices compounded by widespread obstacles in accessing care, prime insurance coverage executives warned Thursday that the state’s well being care system is at a breaking level.
New fee fashions may assist alleviate the trade’s monetary woes, significantly within the major care panorama, they stated.
The heads of Blue Cross Blue Defend of Massachusetts, Fallon Well being and WellSense Well being Plan provided their sobering views on value and entry challenges in entrance of a whole bunch of well being care suppliers gathered on the Massachusetts Well being and Hospital Affiliation’s annual assembly on the Westin Seaport.
“The challenges, irrespective of the place you sit within the well being care ecosystem proper now, are profound,” Sarah Iselin, CEO of Blue Cross Blue Defend of Massachusetts, stated throughout a panel dialogue.
Iselin invoked practically double-digit well being care value tendencies, which she attributed to steeper medicines costs like GLP-1 weight-loss medicine and “increased utilization will increase throughout the board.” Iselin stated these tendencies are driving losses amongst well being insurers. Blue Cross had a “fairly tough” final 12 months, and that pattern is anticipated by way of 2025, she stated.
“It will have penalties that I feel ought to concern all the native payers as a result of the sooner well being care prices develop, the extra tempting it’s for employers to go self-insured,” stated Iselin, who warned that may “invite extra of the nationwide payers into the market.”
Echoing Iselin’s evaluation, Fallon Well being CEO Manny Lopes stated each suppliers and payers are at a “disaster level.” In the meantime, WellSense Well being Plan President Heather Thiltgen stated Massachusetts is “actually beginning to attain the boundaries of affordability, for our shoppers, our employers and our taxpayers.”
Panelists additionally mentioned initiatives their organizations are pursuing to handle well being care prices and bolster entry, with a watch towards pinpointing potential statewide methods.
Assistant Secretary for MassHealth Mike Levine stated state officers over the past two years “considerably elevated” funding in major care by embracing a capitated fee mannequin relatively than a fee-for-service construction. That transfer creates a extra predictable month-to-month income stream for major care practices, Levine stated.
“I don’t suppose there are sufficient practices in Massachusetts with a excessive sufficient Medicaid payer combine for that to be the factor alone that can remodel care and expertise for suppliers and members,” Levine stated. “However we’re desperate to associate with suppliers and different payers to construct a mannequin of capitation within the major care setting that can hopefully unlock a few of the entry that has been so exhausting to seek out.”
Gov. Maura Healey and Senate President Karen Spilka have pegged major care as a precedence for the brand new legislative session. A major care activity power, established by way of the brand new hospital oversight regulation, will produce suggestions to enhance care entry, supply and monetary sustainability.
Healey, throughout remarks earlier Thursday on the MHA assembly, stated her fiscal 2026 finances proposal appears to spice up MassHealth funding in major care to “10% of its whole spend transferring ahead.”
“We all know that with out that correct funding, we will’t help our major care workforce, we will’t give sufferers higher entry to the care they deserve,” the governor stated. “And we expect there’s a chance for all of us collectively to take a look at how we will prioritize major care.”
Lopes highlighted one other capitated program at Fallon Well being, which he stated serves the frailest aged members who’re thought of eligible for nursing houses however obtain complete at-home care.
“The purpose is to attempt to preserve these people out of establishments, residing locally and residing wholesome locally, and produce all of the help providers for them and their households,” Lopes stated. “Once I take a look at that mannequin, it truly is a mannequin that we will apply to different frail populations or severely sick populations, the place we actually create an surroundings of capitated fee — create an surroundings the place somebody can are available in and get the care that they want.”
Thiltgen stated WellSense, which serves a big share of individuals with Medicaid and highly-subsidized ConnectorCare protection, stated members have “appreciable entry issues” for behavioral and first care. She stated the well being plan is exploring easy methods to higher combine care, together with for people with substance use dysfunction.
“We’re experimenting with placing nurse practitioners in suppliers’ places of work in order that we can assist suppliers extra effectively perceive who wants the care, and supply that bridge and assist enhance general high quality,” Thiltgen stated.