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Universal Coverage in Place, Massachusetts Neurologists See Few Changes

Family practice physicians in Massachusetts have seen a tidal wave of new patients since the state adopted a form of universal health care two years ago. In April, the New York Times reported that some general practitioners are seeing four to six new patients a day, while others are so busy that they cannot take on any new patients until next year.

But that deluge of new patients seen by general practitioners appears to be, at most, a trickle in the offices of Massachusetts neurologists. Several leading neurologists in the state tell Neurology Today that the impact of the new law on their practices so far has been fairly minimal.

“We have seen a few more patients [due to universal coverage], but it hasn't been an increase in droves,” reports Gigi Girgis, MD, president of the Massachusetts Neurological Association and medical director of the stroke service at Beth Israel-Deaconess Hospital in Needham. “I hear the same thing from my colleagues.”

Enacted in April 2006, the Massachusetts health reform plan expands the state's Medicaid program and creates a new private insurance plan open to individuals. It also offers income-related subsidies, and mandates participation in the health insurance system by both individuals and employers.

A June 2008 report from the Commonwealth Fund found that the new system has led to “impressive gains in coverage,” with the uninsured rate for adults with incomes below 300 percent of the poverty level dropping by 11 percent, and the rate for those with incomes below 100 percent of poverty dropping by more than two-thirds.

THE EFFECT ON NEUROLOGY CASELOADS

But although the Commonwealth Fund report found that this increase in coverage translated to significant gains in access to care, neurologists like Anna Hohler, MD, haven't seen much of a difference in their caseloads.

“Here in the city hospital, we've always worked with a large uninsured population. Previously, they would be registered for Medicare, Medicaid, or under our free care system, where the state would help to underwrite the cost of their care,” said Dr. Hohler, an assistant professor of neurology at Boston University Medical Center. “We never had a large population of people who didn't qualify for state aid and who also didn't have their own insurance. For the small group to whom that does apply, we just have to do a little more paperwork now.”

Of the handful of new patients who come to her practice each month because they now have medical coverage, many may not actually have neurologic conditions, said Dr. Girgis. “These are patients who have seen their primary care provider for a problem, and the primary care provider sent them to me for a neurological workup because of the availability of a neurologist,” she explained. “But a lot of these patients really aren't neurologically sick. Their conditions reflect the fact that they've had very poor health care maintenance.”

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DR. RACHEL NARDIN: “Theres nothing in the plan that constrains costs. Premiums continue to rise at twice the rate of inflation, and there is a 4 percent surcharge on each policy just because of the cost of running the Commonwealth Connector [the system that helps Massachusetts residents find coverage].”

RATING THE NEW PLAN

Although it hasn't changed their own practices much, neurologists generally praised Massachusetts' universal coverage initiative. “I think it's a wonderful thing,” said Dr. Girgis. “The new availability of health care services really has made a difference in primary care and the ability to offer people good health maintenance. What has yet to be seen is whether it's going to last. We already are hearing that they may not have the money to be able to handle the extra numbers, so we'll see if it's going to be sustainable.”

But the transition to universal coverage hasn't been completely smooth, said Rachel Nardin, MD, an assistant professor of neurology at Harvard Medical School. As an example, she cited the case of a current patient, a 47-year-old man with chronic medical problems, including diabetes mellitus complicated by polyneuropathy, chronic renal insufficiency due to IgA nephropathy, hypertension, hyperlipidemia, and spinal stenosis. After evaluating him for progressive gait difficulties and receiving an EMG report suggesting myopathy in proximal muscles, Dr. Nardin performed a muscle biopsy and sought additional tests to see if the patient had a muscular dystrophy.

The patient had been receiving “free care” before the reform, and was now insured by a private insurer, the Neighborhood Health Plan (NHP). But when Dr. Nardin sought approval for the tests, NHP told her that his coverage had been cancelled. Neither he nor the company knew why.

“He still can't figure out why he was dropped, but his coverage was supposed to be reinstated in November,” Dr. Nardin said. “His care was never disrupted under free care, and it is a disaster for a patient like this, with so many chronic medical problems, to be without coverage for two months.

“Private plans are notorious for rejecting coverage and mysteriously dropping coverage. Their bottom line improves when they don't cover expensive patients like this one. I have heard many similar stories from primary care providers in my work with the non-profit organization Physicians for a National Health Program, so I don't think this is just an isolated case.”

Dr. Nardin also noted that when patients like this one were treated under the “free care” plan, the entire state's subsidy went directly to the doctors and hospitals to pay for care; now it goes to the insurers, and some 10 percent stays there to cover “administrative costs.”

“The state claims that 439,000 people have gotten private insurance plans because of the mandate, which is great, but you have to realize that a lot of these people were being cared for with state money under the free care pool before,” she said. “Now, there's just a transfer of state money to what I would say is a less efficient system.”

Dr. Nardin worries that the “incremental reform” of the Massachusetts plan will die a quiet death after a few years, as has happened in other cases. “There's nothing in the plan that constrains costs,” she said. “Premiums continue to rise at twice the rate of inflation, and there is a 4 percent surcharge on each policy just because of the cost of running the Commonwealth Connector [the system that helps Massachusetts residents find coverage]. Projected sources of revenue for the plan, like the fee that businesses were supposed to pay for not insuring workers, haven't been robust.”

According to the Boston Globe, cost estimates show the program reaching 342,000 people and $1.35 billion in annual expenses by June 2011. That's a huge increase over original expectations, largely because state officials underestimated the number of uninsured residents.

On Nov. 4, voters in 10 Massachusetts districts overwhelmingly supported a ballot question that instructs their representatives to support legislation “creating a cost-effective single payer health insurance system that is available to all residents, and oppose laws penalizing those who fail to obtain health insurance.” (The overall margin was 72 percent in favor, 28 percent opposed.)

“The problem with our health care system, and with Massachusetts health care reform as well, is that it relies on so many multiple private plans,” noted Dr. Nardin, who also supports a single-payer approach. “Any plans that leave this structure in place are always going to be subject to people losing their coverage if there's some change in work or income status. It's incredibly important for people to have an accurate picture of the pros and cons of Massachusetts' health reform as President-elect Obama considers a national plan with many similar features.”