The caregiving professions are extraordinarily rewarding – but also extraordinarily difficult. And at times hospital employment can be dangerous as caregivers can face environmental risk and violence from the public. Massachusetts hospitals – through enhanced security protocols, sharing of best-practice violence prevention strategies, design of workplaces, and more – have attempted to keep patients and workers safe.

But now, MHA is filing legislation to etch into law rules to help foster safer hospital workplaces. The proposed legislation directs the Department of Public Health to develop statewide standards for evaluating and addressing security risks within hospitals. Hospitals will document compliance with the standards, and file and regularly update their operational risk assessment policies with DPH.

MHA’s proposal will also ensure improved information-sharing between the healthcare and public safety communities, and strengthens penalties against those convicted of crimes against healthcare personnel. It will also take steps to support victims of workplace violence through the legal process.

The bill reflects recommendations made by MHA’s Workplace Safety and Violence Prevention workgroup, a multidisciplinary selection of healthcare clinicians, operations and security staff from hospitals throughout Massachusetts brought together to find actionable solutions to workplace violence in healthcare settings. The workgroup’s efforts have been inspired by Elise Wilson and her employer, Harrington Hospital, whose individual and collective responses to Ms. Wilson’s brutal workplace attack demonstrated both strength and a deep commitment to making timely, concrete improvements to hospital worker safety.

“Those in the caregiving professions perform extraordinarily difficult work on behalf patients, and their jobs are filled with daily emotional stresses,” said MHA President & CEO Steve Walsh. “We owe it to all who care for us to do our best to protect them as they go about their work.  Through adherence to proven violence-prevention standards and tracking compliance, providing senior support for in-house hospital incidents, enhancing penalties for violent acts committed against healthcare providers, and better sharing of information between the healthcare and public safety communities, we can help ensure the safety and well-being of our hospital workforce.”

A paper released last week by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society, and Massachusetts Health & Hospital Association has raised the alarm on the pervasive problem of physician burnout.

The paper, available here, includes directives aimed toward curbing the prevalence of burnout among physicians and other care providers, including the appointment of an executive-level chief wellness officer at every major healthcare organization, proactive mental health treatment and support for caregivers experiencing burnout, and improvements to the efficiency of electronic health records.

In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians surveyed said they experience some degree of professional burnout – a syndrome involving one or more of the symptoms of emotional exhaustion, depersonalization, and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession.

“The issue of burnout is something we take incredibly seriously because physician wellbeing is linked to providing quality care and favorable outcomes for our patients,” said Alain A. Chaoui, M.D., a practicing family physician and president of the Massachusetts Medical Society.  “We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

“Massachusetts hospitals place a high and unwavering priority on the safety and wellbeing of patients and everyone who works in or visits their facilities,” said Steven Defossez, M.D., MHA’s V.P. of clinical integration, a practicing radiologist, and a co-author on the new report. “In particular, we recognize the need to further empower healthcare providers and support their emotional, physical, social and intellectual health. This report and its recommendations offer an important advance toward ensuring that physicians are able to bring their best selves to their lifesaving work. We see it as a component of our broader efforts to improve the healthcare workplace for every single employee, from nurses and direct care workers to lab technicians and administrative personnel.”

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000 and $1 million.

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” said Ashish K. Jha, M.D., director of the Harvard Global Health Institute and K.T. Li professor of global health at Harvard T.H. Chan School of Public Health. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

In addition to Chaoui, Defossez, and Jha, the paper’s authors are Andrew R. Iliff, J.D., program manager, Harvard Global Health Institute; Maryanne C. Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael R. Miller, MBA, director of practice solutions and medical economics, Massachusetts Medical Society.

In a letter to CMS last week, MHA urged the federal agency to reconsider rules regarding how Medicaid Managed Care Organizations (MCOs) direct payments to providers.

Following substantial changes in 2016, CMS recently proposed modest updates to its Medicaid managed care rules. In its letter, MHA reiterated concerns stemming from changes made in the 2016 final rule that, among other complex provisions, preclude state Medicaid authorities from stepping into MCO/provider negotiations to, in effect, set rates. But that 2016 rule also allowed states to set “minimum” and “maximum” fee schedules. In 2016 comments, MHA raised concerns with this provision, arguing at the time that MCOs, given minimums and maximums, would default to those limits and providers would be forced to accept them.

In last week’s letter to CMS, MHA’s Senior Director of State Government Finance and Policy Daniel McHale wrote, “Just as we predicted a problem in 2016, it has now become a reality.” In 2017, Massachusetts restricted MassHealth MCO reimbursements to 105% of the MassHealth fee-for-service rates for in-network acute care hospital services. Effective March 1, 2018, the limit was dropped to 100% of the fee-for-service rate. The policy also applies to MCOs that fully integrate with Accountable Care Organizations (ACOs) as part of the state’s sweeping and forward-thinking MassHealth ACO initiative that went live March 1, 2018.

McHale wrote that on one hand CMS issued a rule effectively prohibiting state Medicaid agencies from directing how its MCO contractors reimburse healthcare providers, but on the other hand it has allowed a state to set a maximum fee schedule tied to the Medicaid rates the state itself sets.  In the case of Massachusetts, this effectively has exempted the state from the rule prohibiting the directing of payments and has resulted in de facto rate setting.

“The ability of hospitals and other providers to negotiate independently with MCOs is critical to ensure the added value a hospital may provide to support care management of MCO enrollees and to be a high-quality, key network provider for the MCO in a particular service area,” MHA’s letter states. “For many ACOs, hospitals serve as key elements to their model and provide much of the financial backing that will affect the ability of these ACOs to succeed. The limitations on reimbursement rates with MassHealth MCOs will make it difficult for many hospitals to continue critical community care initiatives on fragile financial margins. The ability to negotiate is also needed to minimize the likelihood they will be taken advantage of financially by non-network ACOs/MCOs.”

The lack of negotiating flexibility between providers and MCOs/ACOs has consequences. Earlier this month UMass Memorial Health Care announced 170 layoffs that the hospital attributed mainly to the MCO contracting issue. In an interview with the Boston Business Journal, UMass Memorial Health Care CEO Eric Dickson, M.D., said the system’s inability to negotiate rates reduced reimbursements to his system by $40 million, resulting in the layoffs.

“I understood what the state was trying to do by leveling the playing field by lowering reimbursements across the state, but it had a very negative impact on us — a disproportionate impact because of who we are and who we care for,” Dickson said in the interview, noting his system’s high proportion of MassHealth patients.

The American Hospital Association released a report last week showing that total drug spending per hospital admission increased 18.5% between FYs 2015 and 2017. Hospitals experienced price increases in excess of 80% across different classes of drugs, including those for anesthetics, parenteral solutions, opioid agonists, and chemotherapy. More than 90% of surveyed hospitals reported having to identify alternative therapies to mitigate the impact of drug price increases and shortages. And one in four hospitals had to cut staff to mitigate budget pressures.

"This report confirms that we are in the midst of a prescription drug spending crisis that threatens patient access to care and hospitals' and health systems' ability to provide the highest quality of care," said AHA President and CEO Rick Pollack. The new Congress has already begun to hold hearing on prescription drug prices.

The report, prepared by NORC at the University of Chicago for AHA, Federation of American Hospitals and American Society of Health-System Pharmacists, is available here.

Hospitals and health systems may apply through February 19 for the 2019 AHA Equity of Care Award, which recognizes organizations participating in the AHA's #123forEquity campaign for extraordinary success in advancing diversity and equity through data collection, leadership, cultural awareness, and partnerships. The awards will be presented at the AHA Leadership Summit, July 25-27 in San Diego. To learn more and apply, click here.

In this program, participants will learn the fundamentals of continuous improvement in a classroom setting. They will then work in teams to apply the principles and tools of continuous improvement in an actual healthcare process at Emerson Hospital in Concord, Mass. Each day participants will be introduced to appropriate best practices to address the challenges facing healthcare professionals. This learn-by-doing method will prepare students to return to their own workplaces with the confidence to implement continuous improvement methodologies. The program will be held at Emerson Hospital so that a combination of classroom and hands-on learning can take place.  The program runs on eight consecutive Wednesdays, starting Wednesday, March 6, 2019. Learn more and register by clicking here.