Fulfilling a campaign promise, but angering a wide swath of hospitals, physicians, healthcare insurers, patient advocacy groups, and other interests with an interest in practical healthcare policy, President Donald Trump this week issued two decisions to destabilize portions of the Affordable Care Act (ACA) .

First he issued an executive order that would allow small businesses to band together to create “association health plans” that essentially would be covered not by state insurance regulators but rather by federal employment law. The order also directs federal agencies to consider expanding the availability of short-term, low-cost health reimbursement arrangements.

Later on Thursday, President Trump said he would end – perhaps as soon as month’s end – cost-sharing reduction (CSR) payments that help lower-income people afford co-pays and deductibles on health plans they buy through insurance exchanges. About 80,000 people in Massachusetts would be affected directly by the loss of subsidies but the broad impact on the state would be deep.

On Friday, Massachusetts Attorney General Maura Healey (D) joined a lawsuit filed by California’s Attorney General, along with other states, to prevent the president from cutting off the CSR payments.

“The loss of funds and financial uncertainty caused by their actions will lead to higher health insurance costs for consumers and to insurers abandoning the individual health insurance market. The number of uninsured Americans will increase once again, hurting vulnerable individuals and directly burdening the States,” the complaint states.

MHA’s President & CEO Lynn Nicholas, FACHE, applauded Healey’s action, calling it an “upstanding effort to protect access to high-quality, affordable healthcare in our commonwealth and across the country.” (See MHA’s full statement here.)

Republican Governor Charlie Baker also criticized elimination of the cost sharing reductions and called on Congress to take “immediate action” to appropriate funding for the CSRs.

The executive order relating to association health plans also caused concern. Such plans could offer skimpier benefits than required by the ACA and could skirt the prohibition against charging higher premiums to those with preexisting conditions. Such association plans have failed in the past because while they need to be well capitalized, established insurance plans have avoided them.

The American Hospital Association responded on Thursday, stating, “Today’s Executive Order will allow health insurance plans that cover fewer benefits and offer fewer consumer protections. No one can predict future healthcare needs with complete certainty and such plans could put patients at risk when care is needed most. In addition, these provisions could destabilize the individual and small group markets, leaving millions of Americans who need comprehensive coverage to manage chronic and other pre-existing conditions, as well as protection against unforeseen illness and injury, without affordable options.”

MHA’s Nicholas, said, "President Trump's irresponsible decision to discontinue federal insurance cost-sharing reduction subsidies is a devastating one-two punch coming on the heels of yesterday’s Executive Order that could undermine current consumer insurance protections that are especially important to older, sicker, and poorer Americans with private or work-sponsored insurance. These announcements will be particularly disruptive to the Massachusetts healthcare system, as the commonwealth has been structuring the upcoming 2018 open enrollment offerings – now just weeks away – based on some $146 million in previously agreed-to federal support.”

A deficiency budget that the Massachusetts House passed this week to close the books on FY17 included a provision requiring every employer in Massachusetts with six or more workers to out an employer medical assistance contribution (EMAC) compliance form and submit it to MassHealth. The form details whether the employer has offered health coverage to its workers, what benefits are offered, cost-sharing details, and more.

The compliance form was one part of a MassHealth reform packaged that Governor Charlie Baker had offered back in July; the form’s purpose was to enable the state to determine which MassHealth enrollees have access to employer-sponsored health coverage, which in turn helps the state collect a new employer assessment.

When the state Senate passed its own deficiency budget package Thursday, it did not include the compliance form. However, the Senate is expected to release a comprehensive healthcare reform package soon – rumored for this week – and provisions addressing the compliance form may be included as part of that package.

A key outstanding budget item in need of attention is the Senate override of a $209 million reduction to MassHealth line-item 4000-0700 of the state’s FY2018 state budget. When the governor signed the increase in the employer medical assistance contribution into law, the need for the $209 million cut was eliminated. Last month, the House took action to restore this essential funding, but the Senate has yet to follow suit. As MHA noted in correspondence to the legislature, “Without this restoration, MHA is very concerned that the administration will need to take action that will negatively affect MassHealth enrollees and healthcare providers.”

MHA also expressed its thanks to both the Senate and House for including provisions in their respective supplemental budgets to permit the Executive Office of Administration & Finance to transfer up to $15 million from the Commonwealth Care Trust Fund to support the Health Safety Net, thereby maintaining a portion of the required state’s share of responsibility to support that program. Governor Charlie Baker had included this language in a supplemental budget filed in February.

This week, both branches of the legislature adopted provisions in separate supplemental budgets that would ban devices attached to a firearm that are designed to increase the weapon’s rate of discharge. The legislative action quickly followed the October 1 shooting in Las Vegas that left 58 people dead and nearly 500 injured. The shooter used “bump stocks” on his semi-automatic rifles that allowed them to fire at a rate similar to that of an automatic weapon or “machine gun.” The Senate language – offered by State Senator Cynthia Creem (D-Newton) and Senate Minority Bruce Tarr (R-Gloucester) – differs from the House language offered by State Rep. David Linsky (D-Natick) in that it is more specific as to what specific types of attachments would be banned, and offers some exceptions for use of the devices by firearms instructors and certified gun collectors. The two branches will now attempt to resolve issues between the two bills. Governor Baker has indicated he is receptive to the concept of restricting bump stocks. Hospital personnel on a daily basis see the terrible results of the nation’s gun violence and mass shootings, and many in the healthcare community view such violence as a true public health threat.

Quality improvement leaders from Massachusetts hospitals and patient safety organizations met at MHA headquarters in Burlington on Wednesday to have a focused conversation on whether to, and how to, align the numerous healthcare quality initiatives now occurring across the commonwealth. Questions posed throughout the half-day forum centered on: which topic areas should the healthcare community focus on (ex. Readmissions? Opioids? Employee burnout? Etc.). How do you get hospital leadership, and state officials, engaged? How exactly would coordination work? And, importantly, would a new, coordinated effort duplicate other efforts now underway in the state?

Laura Adams, president and CEO of the Rhode Island Quality Institute, and Sam Watson, SVP for Patient Safety and Quality at the Michigan Health & Hospital Association and executive director of the Keystone Center for Patient Safety presented on their success in building alignment on high-quality care. Attendees then broke off into a series of rapid-fire thought exercises to narrow down the focus.

What was the final takeaway? Pat Noga, R.N., FAAN, MHA’s VP of Clinical Affairs, “There was consensus that a unified, coordinated response to a single quality issue – with definable goals and conditions to ensure that the combined effort would be meaningful and not burdensome – would be a way to move the needle on quality improvement in the state.” Noga said she is assembling a smaller coordinating group to work on the next steps of the process.

The Organization of Nurse Leaders of Massachusetts, Rhode Island, New Hampshire, and Connecticut now has added Vermont to its organization. ONL President Joanne Fucile, R.N.,  who is VP of Operations and Director of Nursing at Spaulding Hospital for Continuing Medical Care Cambridge, said of the merger that was approved at ONL’s quarterly meeting, "This successful vote is the culmination of more than three years of collaboration and ongoing discussions between the two organizations. We look forward to working closely with Vermont Organization of Nurse Leaders to fully incorporate their membership into ONL."

MHA, the Organization of Nurse Leaders of MA, RI, NH, CT & VT, and the Home Care Alliance of Massachusetts have posted the latest available national quality performance measures for both hospitals and home healthcare agencies in Massachusetts. Data from Medicare’s Hospital Compare and Home Health Compare are now available on the PatientCareLink website for 58 Bay State acute care hospitals (66 total hospital campuses) and 97 Bay State home health agencies.

This quarter’s reported CMS measures for hospitals include the annual update of mortality and readmission data from July 1, 2013, through the second quarter of 2016, in addition to the usual quarterly reported timely and effective care measures for stroke, heart attack, heart failure, blood clot prevention and treatment, and pneumonia. For home care agencies, the reported measures include timely initiation of care, patient/family medication education, depression assessment, and more. In addition, PatientCareLink collects and publicly provides data on pressure ulcers, falls, and falls with injury for 74 hospitals in the state.

Massachusetts was the first state to voluntarily make hospital staffing and nursing-sensitive quality information public starting in 2006. Home Care Alliance of Massachusetts joined the PCL quality and patient safety transparency effort in 2013.

Fraud & Abuse Update: Recent Healthcare Investigation Trends

Wednesday, October 25; 9 a.m. – 12 p.m.
MHA Conference Center, Burlington, Mass.

Over the last few years, the Departments of Justice and Health & Human Services have increased their scrutiny of healthcare providers, which has resulted in a broad range of investigations from the FBI, U.S. Attorney Offices, and the FDA into hospitals, skilled nursing facilities, and other providers. There has been no sign that investigations will decrease under the new administration. Healthcare providers should be aware of the trends and areas that the federal government is pursuing and must be prepared for what to expect in light of developments in integrated care delivery models that include mergers, accountable care organizations, and affiliations.  All provider organizations are encouraged to attend this timely session where we plan to review current government scrutiny and provide guidance on how to respond if the government does initiate an inquiry. Giselle Joffre, a partner with MHA’s member law firm of Foley Hoag (and a former Assistant U.S. Attorney within the Civil & Criminal Divisions of the U.S. Attorney's Office in Boston) will be presenting along with other healthcare law experts from Foley Hoag.  Visit here for more information and registration details.