Survey of Massachusetts Outreach and Enrollment Workers …

Survey of Massachusetts Outreach and Enrollment Workers
      Regarding 2008 Commonwealth Care Co-pays




          Developed and compiled by Community Partners

                          February 2008




                       24 South Prospect Street
                         Amherst, MA 01002
                           (413) 253-4283

                       www.compartners.org
                       info@compartners.org
      Survey of Massachusetts Outreach and Enrollment Workers
            Regarding 2008 Commonwealth Care Co-pays

                                **SUMMARY OF RESPONSES**
                                      February 26, 2008


Background
Community Partners conducted a survey of Massachusetts outreach and enrollment workers
throughout the Commonwealth to gauge the impact of proposed changes to the Commonwealth
Care co-payment schedule for 2008. The survey was conducted online between February 22 and
February 26, 2008.

A total of 48 people responded to the survey. Respondents offering contact information
represented 26 organizations in 14 towns/cities in the Commonwealth. These respondents live
and work in communities from Boston to Pittsfield, in cities and rural areas. The vast majority of
those who identified their role are professionals who provide enrollment assistance: they
represent hospitals, community health centers, and a variety of community-based organizations.
Others are members of Commonwealth Care or medical providers for Commonwealth Care
patients.


Key Findings
The key finding of this targeted survey is that the proposed 2008 co-payment schedule for
Commonwealth Care is perceived to be a barrier to health care for those enrolled in the program.
Three specific themes emerged from the responses.

1. Respondents indicated that an increase in co-payments for Commonwealth Care would
   be unaffordable for members, resulting in a negative impact on members' access to
   care.

    Concerns about what a Commonwealth Care plan will cost are usually the first or second
    questions from new applicants. Increases of any amounts for those living at $10-30K/year
    income levels will likely result in postponing or avoiding routine care, prescription
    medication or worse, an ER visit. (p. 5)

    They will go to the emergency rooms of hospitals when they are so sick they cannot stand it
    anymore but will not come to have their day to day needs met at the clinic. (p. 5)

    These are people who are trying to make ends meet. If they need to choose between the co-
    pay or a heating bill or food bill they will do without the co-pay and the service that is
    medically needed. (p. 7)

    Pharmacy co-payments have a disproportionate adverse effect on low income chronically ill
    people. They both impose a financial strain and make it more likely that a person will not
    comply with their pharmacy regime, which is what is keeping them from getting sicker. (p. 7)

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2. Respondents suggested that changes to co-pays were too soon.

    Cost increases in a year or two may be appropriate and necessary, and may not affect some
    enrollees. However, I fear that there is a population within those who have just enrolled in
    Commonwealth Care plans who will despair and drop their coverage when they see costs
    rising so soon after enrollment. (p. 9)


3. Respondents expressed concern that the combination of co-pay increases and expected
   premium increases would have the effect of making health care coverage costs too great
   for some Commonwealth Care members to afford.

    If a Commonwealth Care member can scrape together enough money for a hike in their
    Commonwealth Care premium, they surely won't have additional money in their already
    strapped budget to pay for higher co-pays . . . Serious medical conditions will go untreated
    and unmedicated because the chronically ill will not be able to pay for their inflated co-pays.
    (p. 11)

    The patients won't pay their co-pay/premiums and they will be taken off CommCare thinking
    they will be eligible for the Health Safety Net again and [that] this will count as insurance.
    (p. 11)




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Organizations Responding to Survey (when identified; 36 of 48 responding)

 Artists Foundation                                  Boston
 Baystate Medical Center                             Springfield
 Beverly Hospital                                    Beverly
 Beth Israel-Deaconess Needham Hospital              Needham
 BMC HealthNet Plan                                  ---
 Boston ABCD                                         Boston
 Brigham and Women's Hospital                        Boston
 Caring Health Center                                Springfield
 Community Health Center of Franklin County          Turners Falls
 Duffy Health Center                                 Hyannis
 Elder Services of Berkshire County                  Pittsfield
 Gateway Health Access Program (GHAP)                Gardner
 Great Brook Valley Health Center                    Worcester
 Hampshire HealthConnect                             Northampton
 Health Care for All                                 Boston
 Health Law Advocates                                Boston
 Health Quarters                                     Beverly
 Healthy Connections                                 Orange
 Lazarus House, Inc.                                 Lawrence
 Manet Community Health Center                       Quincy
 Mass General Hospital                               Boston
 Neighbor to Neighbor MA                             Boston
 Outer Cape Health Service                           Orleans, Truro
 People Acting in Community Endeavors (PACE)         New Bedford
 Sidney Borum, Jr. Health Center                     Boston
 Stanley Street Treatment & Resources                Fall River


Role of Respondent (when identified; 46 of 48 responding)

 I help people enroll in Commonwealth Care                  83.3%
 I am a member of Commonwealth Care                         8.3%
 I am a medical provider who has patients on
                                                            8.3%
 Commonwealth Care



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RESPONSES

"What impact do you expect the co-payments for Commonwealth Care
proposed by the Connector to have on you/your clients/your patients?"

CO-PAYMENTS NOT AFFORDABLE


 When we help a new member choose their plan, we also explain to the member the benefits
 and co-payments specific to that plan choice they've made. Even with the current prescription
 co-payment structure, I shudder each time I say out loud the co-payment figure for "non
 preferred" or "Tier 3" medications. As it stands now, these co-payments are $30 and $40 for
 plan types II-IV. I myself am not dependent on medications so it's hard for me to imagine what
 it must be like for someone that pays $30-200/month in just pharmacy co-pays on top of $70-
 105/month for their plan premium. It is, in my opinion, unthinkable to even consider raising
 co-payment amounts or out-of-pocket maximums.

 Before Commonwealth Care, many of the rural people I work with were [Free Care] Pool
 members and received necessary "non preferred" medications either by paying a small co-
 payment to their Community Health Center pharmacy or for free through a Patient Assistance
 Program (PAP). Now that Pool members have been converted and enrolled in Commonwealth
 Care, they are no longer eligible to participate in PAPs, because they now have health
 insurance with Rx coverage. Convincing many Pool members to sign up with CommCare was
 easy, because we could say with enthusiasm that they'd now have stable, affordable drug
 coverage. People bought into this program because we helped them to believe that finally
 their day had come. Finally, their Commonwealth was concerned with providing an
 affordable lasting alternative.

 Health Care Reform was intended to drive down costs for both consumers and government.
 The proposed increase in co-payments looks more like cost shifting than cost sharing. There
 are many other more logical tools at the disposal of legislature and the Connector to leverage
 financing for this program.

 Any time costs increase, it adversely affects our clients. Given the state of the economy now
 (i.e., housing crisis, high gas costs, etc.), increasing mandated health costs is burdensome.

 Patients that are chronically ill have been complaining that for the amount of appointments
 they have, they can not afford to pay co-pays at every visit, plus co-pays for every prescription,
 plus their monthly premium, plus payments at dental department because they do not have full
 coverage under the Health Safety Net. I have a few patients that are refusing to pay co-pays
 because of the simple reason that they do not have enough money for all these co-pays.
 Increasing the co-pays or premiums will just make these chronically ill patients not seek
 further medical and dental care and can interfere with the medical provider plan of care.

 If the co-payment goes up the clients will not be able to afford the Commonwealth Care plan.


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 Concerns about what a Commonwealth Care plan will cost are usually the first or second
 questions from new applicants. Increases of any amounts for those living at $10-30K/year
 income levels will likely result in postponing or avoiding routine care, prescription medication
 or worse, an ER visit.

 I think the proposed increase may push some individuals to drop off the program in which they
 are enrolled.

 Higher co-payments mean that my employees will not get health care they need. They'll put off
 doctor visits until they are emergencies, which is a terrible way to deliver health care.

 Patients won't be able to pay and will result in cost shifting to providers.

 I believe that they should be responsible for co-pays at any cost as many people have much
 higher premiums and co-pays and they are responsible for them so why shouldn't
 Commonwealth Care [members] not share in the responsibility for their health care.

 Increased co-pays will stop many clients from accessing necessary medication and office
 visits, which leads to increased medical complications and costs.

 Clients and patients are going to have a hard time with this decision -- many of them cannot
 afford current co-payments and now we are talking about raising them? I anticipate a very
 large uproar over this and I also think that some people will rethink their decisions about
 Commonwealth Care. The sad thing is, that no matter what the co-payments change to, the
 outcome is still far less expensive than the alternative of private insurance. We need to work
 on stressing that fact to these people while we are proposing higher co-pays.

 A lot of our patients cannot even afford the $5.00 office co-pays now.

 I think that the impact will depend on how much the co-pay will increase. If it goes up to say
 $10.00 per visit, it should be fine.

 It will be devastating. The patient's that I serve who do work only make a minimum of $250.00
 a week. The jobs on Cape Cod are seasonal and the fishermen are getting squeezed to the
 limit. While on paper this sounds super, it is not. Again, patients will not have their health
 care needs met. They will go to the emergency rooms of hospitals when they are so sick they
 cannot stand it anymore but will not come to have their day to day needs met at the clinic. I
 especially see patients who are diabetic. Unable to obtain their insulin because they do not
 have the money go into comas or just about make it to the emergency rooms of hospitals.
 Please reconsider what you are doing to the neediest in Massachusetts.

 Very negative impact on our community. Many artists, like others under 400 percent of the
 FPL, don't have a rainy day fund to cover these increases.


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 ... requiring higher co-pays will put a burden on the patient, as well as the provider. The
 patient is already under a hardship and to be expected to pay a higher co-pay will just add to
 the burden. As a provider, this will increase our bad debt which is already climbing.

 If people are in medical need they will utilize services, this will also reduce routine visits to
 ER's.

 Devastating effect. These people that I have signed up would not be able to afford the
 increased co-pays. I know that for a fact, because I have asked them myself, personally.
 Furthermore, many of them are sick and need a lot of medicine and medical help and they
 don't speak much English. A lot of them smoke, and they need anti-smoking stuff. How can they
 pay for their cigarettes and the patches, too? One woman, Rashonda, told me that if these
 increases happen, then she will probably die because she can't afford them now, never mind
 after they go into affect. And her 5 children are all sick and in special ed. ... So, I hope you
 don't raise the co-pays, but rather either lower or better yet eliminate them all together.
 Remember, "together we can save ... Rashonda and her innocent, lovely children."

 I don't think people will like them, but I think that they are necessary. This program is built on
 a very fragile compact and I think it's important that we do everything we can to stabilize it
 financially while keeping care affordable.

 Patients on the state assisted programs such as HSN Partial often do not pay their portion of
 responsibility and the hospitals end up shouldering the cost. I believe this will make it more
 difficult for patients and may discourage them from seeking care, however, if they do seek
 care, it is likely they will not pay the co-pays and the hospitals will be left with the bad debt.

 I work with individuals who have medical debt that they owe to medical providers such as
 hospitals, ambulance companies, and doctors' groups. Even a modest increase in out-of-
 pocket medical costs can result in medical debt, particularly for low-income or chronically ill
 patients. Although the increases in co-payments may seem trivial, research shows that even
 small amounts of debt can lead to financial and health access problems. A 2005 Access
 Project survey of low and moderate income people at Tax Assistance sites found that 12
 percent of those with less than $500 in debt reported housing problems due to medical costs. 1
 in 6 who owed less than $500 said that the medical debt had harmed their credit.

 More than 10% of the people in our medical debt counseling program owed less than $500 the
 time they sought help from us. Despite these seemingly negligible debts, one man couldn't
 come up with $345 for a root canal that he needed to save his teeth. Another woman owed a
 mere $90 to her university health center, which she was unable to pay. Barred from enrolling
 in classes for the next semester, she was forced to borrow the money from a friend. A third
 person had been black-listed at his primary care provider due to a $240 bill. It is clear that
 even small bills can have serious consequences.




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 If a patient can not afford the co-payments they will do without the service. These are people
 who are trying to make ends meet. If they need to choose between the co-pay or a heating bill
 or food bill they will do without the co-pay and the service that is medically needed.

 "Affordable" is not the same for everyone who has the same income, particularly for folks
 with a high debt load, and/or out of pocket expenses, dependent care, etc. I am a person with
 several chronic diseases and a family income far above 301% of poverty. I can tell you that
 helping three children pay for college (as well as still paying loans for my Master's degree)
 and trying to keep up with rising prices (fuel, food, heat, etc) on a static or declining human
 service worker pay scale, many people will not be able to pay increased co-pays. I have had a
 lot of recovery of my chronic diseases, but for many years I had doctor/medical appointments
 several times every month. Current co-pays may already be keeping folks from getting the
 medical/mental health services they need. We all know that maintaining health is a whole lot
 cheaper than measures taken when condition rises to a crisis level (compare costs of current,
 very expensive hepatitis c treatment vs. liver transplant and lifelong follow up, prescriptions
 and side effects).

 The co-payments will make some members choose not to treat. Other members will return to
 using the ER as a PCP.

 Pharmacy co-payments have a disproportionate adverse effect on low income chronically ill
 people. They both impose a financial strain and make it more likely that a person will not
 comply with their pharmacy regime, which is what is keeping them from getting sicker. In
 addition, although 20 years ago co-payments were adopted by insurers to manage pharmacy
 utilization and expense, the MCOs now employ pharmacy management services, and stress
 generic drugs and comprehensive care/drug management, so there is no longer this rationale
 for co-payments. Leaving one with the conclusion that they are simply a way of making the
 poor pay more money for less service!


 Several of our clients are already having a difficult time paying for co-pays. We anticipate
 that many will delay care because the co-pays are prohibitive. There are also clients who will
 be significantly impacted by the lack of out of pocket limit for Rx. I have one specific client
 who was taxed while waiting for his Rx co-pay reimbursement due to the existing cap- he will
 be unable to pay for all of these drugs and will choose between them. We anticipate filing
 more hardship waiver applications and co-pay waiver applications for our clients.


 I can not afford another dime. My family and I were burnt out in a fire in Lowell last month.
 We are living in a motel. I can't find a job because it's cold. I cut grass for people. Please don't
 raise the money I've got to pay; wait until summer when I'm working.

 The Commonwealth Care insurance that I have does not cover dental as well as other
 important treatments. With increased co-payments, will the services be better?




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 I think it will be difficult for our patients to pay the increased co-pays. I worry that they won't
 come in for care. I also worry that they will come in for care and won't be able to pay their
 co-pay. We will see them but that will place us in a very difficult financial position. We are a
 non-profit healthcare provider and consequently our margins are thin. I am concerned that if
 co-pays increase we will see an increase in bad debt.

 Very large. The pharmacy will not allow people to pick up meds if they can't come up with the
 co-pay. This happens now and will get much worse in the future.


 Patients who cannot pay the co-pays will just not pay the providers who will most likely
 swallow the costs. Our patients will likely be unable to afford any co-pay. We would try to find
 a source to make up the difference. We are rarely able to collect co-pays from our poorest
 patients, but we are committed to providing the care nonetheless.

 Patients are having enough trouble trying to get medical/dental care and prescriptions filled
 because of lack of income. This would definitely make a tremendous negative impact in
 receiving care.




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INCREASE IN CO-PAYS ...TOO SOON


Since I listen every day to clients who have enrolled in Commonwealth Care I believe that right
now, most are overwhelmed with the whole process, but very happy with the result once they
are in the system. I recommend that no increase be given at this time. People have to get used
to paying these premiums. So many now report to me that they are having a hard time with the
current payments that I feel they would drop the coverage if an increase is given. A lot of our
clients are seasonal workers, and in the winter they have a very hard time financially. With the
high price of gas and heat at the present time, I feel our clients would not be able to accept an
increase in a health premium also.

People are just getting used to the Health Care Reform law and making adjustments and
income budgets to help with their premiums and co-pays. To change the costs now would be
upsetting to people and may even cause this insurance to be unaffordable to them. Also, they
may be more inclined to not go to the doctor for check ups or if they do not feel well because
they cannot afford the co-pay. This happens all too often with folks that they do not get
preventative care due to high ins costs and end up getting sicker, which in turn costs the state
more money.

While the overall cost-sharing structure of Commonwealth Care is appropriate and acceptable
to most people I have enrolled, I fear that raising costs to individuals so soon after so many
people have enrolled will discourage Commonwealth Care members from paying their
premiums. Additionally, word of mouth and rumors surrounding "cost hikes" in Commonwealth
Care may dissuade those currently unenrolled from signing up for plans. Cost increases in a
year or two may be appropriate and necessary, and may not affect some enrollees. However, I
fear that there is a population within those who have just enrolled in Commonwealth Care
plans who will despair and drop their coverage when they see costs rising so soon after
enrollment.




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CO-PAYS COMBINED WITH PREMIUMS ARE UNAFFORDABLE


Many of my clients feel that they cannot comfortably afford an increase in their health related
costs. This could discourage consumers from using their insurance and will impact the ability
for the consumers to be able to pay their premiums.

Overwhelmingly, when individuals choose not to enroll in Commonwealth Care it is because
they cannot afford it. The individuals we assist often have many other expenses (i.e. childcare
expenses, education expenses, unsubsidized housing expenses, transportation expenses,
increasing cost of living) and sometimes debt that are not factored in to the eligibility
determination but that make Commonwealth Care premiums and co-payments difficult, and in
some cases unmanageable. If the board's proposed changes take effect, more individuals will
be unable to either enroll in Commonwealth Care plans or to access health services.

Make it less likely for people to stay enrolled. Why participate when the cost of premiums plus
co-pays, etc., is likely to be more expensive than paying fine plus cost of doctor's visits? (That
price comparison will become more realistic each time individuals' "responsibilities"--in other
words, bills--are increased, as will probably happen regularly once the precedent is
established.)

Just paying premiums is a new concept to many of this population. While 35.00 per mo is
certainly a low premium, when you make 18000.00 a year, you are bringing home 300.00 a
week. $35 for a premium you never had before is a big enough bite of your money. Doubling
the co-pays for this population does not seem reasonable. We have many clients that STILL
do not want to enroll because they consider themselves healthy and do not go to the doctors.
They would rather have the 35.00 for other expenses. Also, the hospital is going to be the one
left holding the bag. Patients will present and not have the co pay. We will bill but
realistically, I doubt many people will pay. This is a population that previously had free care.
They have never had to pay a hospital bill.

For many of the patients who come into our hospital for frequent visits and are already pushing
their financial limits to pay a monthly premium there will be definite concerns. We will also see
an increase in missed appointments and an increase in the number of waiver applications that
are being filed.

No doubt they will drop the coverage. It is hard enough to find the uninsured and convince
them that "Affordable" CommCare is for them, but, once they find out how much they will have
to pay it will only scare them away. The existing CommCare clients will probably drop it as
their income is not increasing to accommodate the premium and co-pay increases. We have
heard complaints recently that no dental coverage is available for CommCare clients (BMC)
and they are requesting to go back on MassHealth for the dental coverage.

Patients will not be able to afford the co-pays and may not come in for care when they need it.
Also, as a FQHC, we have limited funding. This could add an additional $25,000 in potential
losses for the Health Center.


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As an advocate I have now worked with many people who for the first time have a primary care
physician, and prescription coverage thanks to the Commonwealth Care program. Previously I
managed a Prescription Assistance Program, and obtained 90 day medications directly from
manufacturers for people on Free Care. With the introduction of Commonwealth Care, the
need for that position has almost been eliminated. I know first hand, that Commonwealth Care
works! My clients are delighted and very appreciative that the State is offering these programs.

Most clients are telling me that they will just about be able to afford the premiums as they are
now. A large number of my clients are on fuel assistance, and many also receive food stamps.
Today at the local the gas stations the price for regular gas was anywhere from $3.13 to $3.19
a gallon. I work in a seasonal community and right now a lot of clients are not working. I have
even had clients tell me that since they did not vote on a ballot for this healthcare bill, they
should not be fined because they did not enroll. Due to these reasons, I do not think that this is
the right time for an increase.

If premiums are raised, people will not be able to afford to continue their Commonwealth Care
coverage. The average Commonwealth Care member has no idea that they can request a
premium hardship waiver, or once they receive the waiver, that the stringent guidelines may be
loosened for them depending on their situation. The average Commonwealth Care member will
go back to being uninsured as they had been before the program came into being.

If a Commonwealth Care member can scrape together enough money for a hike in their
Commonwealth Care premium, they surely won't have additional money in their already
strapped budget to pay for higher co-pays. Commonwealth Care members will refuse to seek
care because they just don't have money floating around to pay the co-pays for doctor's visits.
Serious medical conditions will go untreated and unmedicated because the chronically ill will
not be able to pay for their inflated co-pays. Co-pays are a serious expenditure for these folks
and it is unfair to require these low and medium income people to spend even more money for
the medical care that they desperately need.

The patients won't pay their co-pay/premiums and they will be taken off CommCare thinking
they will be eligible for the Health Safety Net again and this will count as insurance.

I expect that there will be a significant number of people who will not be able to afford these
co-pays and therefore will not seek care. Attaching co-pays to premiums seems to be
counterproductive, if the aim of having health insurance is to encourage people to utilize their
doctor on a regular basis, thereby reducing the cost of health care. Preventative care is once
more compromised. Someone else, presumably insurance companies, is deciding how much
people can afford, without taking into account the costs of fuel, food, house, car etc. We are in
a rural area, so none of these are luxury items. If the goal is to provide health care, co-pays
will defeat the purpose. Next, staffing our facilities with primary care doctors must be looked
at. Then, and only then, will preventative health care approach being the norm. Of course, this
leaves out the role pharmaceutical companies play in all this...

It will be further hardship on most CommCare clients to have an increase in payments/co-


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payments. We see many young, low-income clients who struggle to make payments for this
forced insurance plan.

I have had the Connector/Network Health since August and will be switching over to
Neighborhood Health Plan on March 1st. While on Network Health, I was not working
regularly but I made it a priority to pay the $35.00 monthly fee. It was harder to do the co-pays
to see doctors at MA General and MA Eye and Ear in Cambridge. To someone with a two-week
paycheck of only be $400 or less, to have to pay $50.00 to see a doctor and $35.00 for
prescriptions is very expensive! I would have to decide between eating and getting better! I
don't believe that the co-pays could potentially be going up! How do you expect the working
poor like me, (and I have a BA in Education and many years of teaching experience) to get
ahead? Most of the people on Network Health have much less education than myself and are
working to support families.

We, who have been trying to do the right thing by signing up for the Connector, do not need
another kick in the stomach to our self esteem or to our budgets. I am now a family case
manager for the Native American Head Start in Jamaica Plain but when I first signed up for
The Commonwealth Connector, I was working two jobs and still found it difficult just to live a
normal life. I was very grateful to the Southern Jamaica Plain Health Center for helping me
apply for the health insurance, as I found the website mind boggling and in fact, I had to apply
and send my paperwork in three times before the insurance came thru. What bliss it was to not
be treated like a pariah by health practitioners because I did not have insurance. Please do not
raise the premiums or the co-pays any higher. Perhaps it would help if you really tried to 'walk
the walk and talk the talk' of people like me and of those without degrees. How do you expect
us to pay more? Do you want us to pick up a third or fourth job?

What comes to mind is Jimmy Stewart from that popular Christmas movie where he is talking to
old man Potter. Mr. Potter tells him that the working poor don't need nice houses, they don't
need to have these things and that they can just wait until they retire to get them. Jimmy Stewart
says to Potter, "This rabble that you are talking about, these people do deserve these things...
for they are the ones who do the living and dying in this town and is it too much to ask to give
them four walls and a roof over their heads!" We, the working poor, are the rabble and you
are acting like Mr. Potter.




                        Developed and compiled by Community Partners

                                       24 South Prospect Street
                                         Amherst, MA 01002
                                           (413) 253-4283

                                        www.compartners.org
                                        info@compartners.org                                    12
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