An Act Furthering Health Empowerment and Affordability by Leveraging Transformative Health Care (the HEALTH Act) 

Special Senate Committee on 
Health Care Cost Containment and Reform

The Massachusetts Health & Hospital Association (MHA), on behalf of our member hospitals, health systems, physician organizations, and allied health care providers, appreciates the opportunity to submit comments regarding “An Act Furthering Health Empowerment and Affordability by Leveraging Transformative Health Care (the HEALTH Act)”.  

MHA commends Senate President Rosenberg, Senate Health Care Financing Chairman Welch and the rest of our state senators for keeping their focus on reducing the cost of healthcare in the commonwealth and for advancing steps meant to enhance patient access to healthcare services. The Senate has prioritized many important enablers in this bill, such as expansion of access to telemedicine services, promoting care coordination, minimizing administrative barriers to care, and reducing the growth of pharmaceutical spending, and we look forward to engaging with Senate leaders to ensure that such provisions are enacted in a manner that achieves true progress in these vital areas. However, the potential negative impact of other sections of the bill, taken both respectively and in cumulative, are daunting. We would welcome the opportunity to work with you to best advance our mutual goals of enhancing access to high quality patient care and minimizing costs.  

With this focus in mind, the comments below reflect MHA’s position on many items of importance to the healthcare community. We respectfully request your consideration of these comments and positions.


Provider Price Variation 
The Senate bill would establish a target hospital rate distribution by setting a reimbursement floor at 90% of the statewide relative price. (While not currently specified in the text, we believe the intent is to set the floor at 90% of either the “average” or “median” Statewide Relative Price.) The bill also establishes a target commercial inpatient and outpatient hospital spending growth rate, set at the Medicare market basket increase. After 2022, the bill would allow the newly formed Hospital Alignment and Review Council to redefine both these targets and to impose penalties on carriers and hospitals if these targets are not met.

The Massachusetts Health & Hospital Association agrees in principle to the establishment of a reasonable floor on commercial hospital reimbursement rates and we commend the Senate for its effort to establish this particular element. Our members agree that commercial payment variation between the lowest-paid hospitals and other hospitals is tied to a historical base, and due to a lack of bargaining power, many of the lowest-paid hospitals have been unable to negotiate higher levels of payment. This compromises the sustainability of those hospitals and their ability to provide quality services to the communities they serve.

The MHA Board of Trustees (BoT) earlier this year endorsed the position that, under appropriate Division of Insurance (DoI) oversight, commercial payment rates to the lowest paid hospitals should be increased and that there should be a reasonable floor on these payments with the goal to reduce unwarranted disparity in payments. The MHA Board position is in line with the Special Commission on Provider Price Variation, which recommended a minimum rate or floor for hospitals in Massachusetts and also stated that such a floor should take into account warranted and unwarranted factors for price variation, legislature should determine the formula in conjunction with appropriate state entities. 

In setting the a “Target hospital rate distribution”, the minimum rate of a carrier’s reimbursement for services provided by a hospital, the Senate initially chooses 90% of the statewide commercial relative price in the previous calendar year. (As noted above, we believe a distinction must ultimately be made as to whether this is 90% of the “average” or “median” Statewide Relative Price.) While MHA does not take a formal position on the 90% threshold at this time, the standard this bill sets does not appear to take into account warranted or unwarranted factors for price variation. 
The bill would also establish a “Target hospital growth rate” defined as having the same meaning as “market basket percentage increase” as defined under 42 U.S.C. section 1395ww; in other words it would set a commercial hospital spending growth target at the Medicare market basket increase.  MHA is opposed to the imposition of artificial caps on rates and we have grave concerns about the potential unintended consequences of establishing a spending growth rate target solely for commercial hospital spending that is separate and distinct from, and lower than, the statewide cost growth benchmark. 

Hospital costs are already scrutinized and affected by state law to a significant and unprecedented degree under Chapter 224, which limits statewide Total Healthcare Expenditure (THE) growth. For the first time since the inception of Chapter 224, the statewide spending target for calendar year 2018 will be set at a benchmark equal to potential gross state product minus 0.5 percent, or 3.1% – a change MHA and its members support. Further, the Center for Health Information and Analysis (CHIA) has finalized a proposal to expand the criteria for a health care entity to be referred to the Health Policy Commission (HPC) beyond those entities whose health status adjusted total medical expense growth (HSA TME growth) exceeds the cost growth benchmark to also include those that have HSA-TME growth within 15% below the benchmark –along with other criteria. This could increase the number of providers that could be subject to Performance Improvement Plans (PIPs) since entities with HSA-TME growth rates above 2.6% (not simply those above 3.1%) could be subject to PIPs.  

In light of this, adding another layer of complexity by setting commercial hospital spending growth limits –in isolation from all other market participants – at a lower level than the statewide benchmark and tying the cap to the Medicare inpatient market basket will subject hospitals to a greater degree of downward cost pressure than the rest of the healthcare system at a time of great uncertainty about the stability of the Medicare and Medicaid programs. The Medicare market basket has been lower than the statewide growth benchmark for the past several years, as shown in the table below:

 

As public payers continue to ratchet down payments to providers, setting such an aggressive arbitrary cap on commercial hospital payments alone would greatly limit any ability that hospitals have to cost shift in order to maintain financial viability.

In regards to the proposed penalty authority of the Hospital Alignment and Review Council, we note that the council would penalize “the top 3 hospitals” that contributed to spending if the commercial hospital spending growth targets are not met.  The mechanism proposed in the Senate bill which sets a reimbursement floor and an overall target growth cap (set at the Medicare market basket) could very well result in a situation where the “top 3” hospitals might have had much lower growth rates than the Medicare market basket, but despite that, by virtue of their size alone, could potentially be subject to significant and disproportionate penalties. Even if the target hospital spending growth was missed due to spending increases elsewhere, the top 3 hospitals would be the only ones subject to the penalty. MHA is opposed to this mechanism that penalizes a select group of hospitals for matters beyond their direct control. 

In an ongoing effort to provide higher value healthcare, hospitals and other providers in Massachusetts are moving to alternative payment methods. Policymaking based only on comparing prices instead of total medical expense, and scrutinizing hospital spending in isolation from the rest of the healthcare system, takes a narrow view and could have unintended consequences; accordingly we urge continued movement away from “prices” as the metric of comparison and towards total medical expense (TME).

As noted, MHA supports the establishment of a reasonable floor on commercial payment rates to the lowest paid hospitals in order to reduce unwarranted disparity in payments. While we are opposed to the additional elements and mechanisms related to price variation in the Senate bill, we would welcome the opportunity to work with you on a proposal that meets the tenets of MHA’s position on this issue. 

“Surprise” Bills / Out of Network Billing 
 MHA appreciates and supports the need to protect consumers from surprise billing when they obtain services at an in-network hospital but are treated by an out-of-network physician, as well as for the provision of emergency services rendered by an out-of-network provider. As a member of the Special Commission on Provider Price Variation, MHA supported the following provisions, which as noted in the commission’s report, must be addressed and resolved together as a package: 

1. Consumer awareness of “surprise billing” scenarios, 

2. Patient protections to prevent balance-billing, and 

3. A maximum reasonable provider reimbursement for out-of-network services. 

We fully support consumer protections in the Senate legislation that prohibit balance billing of patients  and hold the member harmless when he or she receives emergency services or surprise bills.  This effectively takes the patient out of the middle of disputes between payers and insurers and is  and is a necessary first step towards fairness in payment for delivery of care in these situations .  MHA also supports using an in network rate to pay providers who may be out of network for a particular product but who otherwise participate with that insurance carrier.  
 
MHA does have concerns regarding the default rates set for providers who have no contractual relationship with the carrier.   Until January 1, 2020, the rates for out-of-network emergency and non-emergency services for these providers would be set at no more than the 80th percentile of all allowed charges for a particular healthcare service performed by a healthcare provider in the same or similar specialty and same geographic region using a benchmarking database specified by the Division of Insurance. 

MHA believes that it is the intention of the Senate legislation to put in place a process that works in a similar manner as other states such as New York, but this is not what the language in the legislation suggests.   In New York, there is no default rate for out of network emergency/non-emergency services. Instead, the law requires that a health plan that writes or issues a comprehensive health insurance policy must make available and, if requested by the policy holder, provide at least one option for coverage for at least 80% of the usual and customary cost, after application of the patient’s cost share. Usual and customary is defined as the 80th percentile of all charges (not all “allowed” charges) for a particular specialty provided in the same geographic area, according to their benchmarking database.  This is completely different than setting a default rate using these parameters.   

Once this provision for establishing a default rate at the 80th percentile expires in December 2019 under the Senate bill, the HPC, under the provisions of section 22, will be responsible for determining the default rates with input from the Division of Insurance.  Notably, these sections give the HPC complete power to recommend non-contracted commercial rates that, once adopted, would be in effect for five years. MHA has significant concerns with changing the fundamental mission of the HPC from a policy-setting organization to a rate-setting entity.  Additionally, these sections include no protections for providers against artificially low rates and no sanctions on insurers that could decide to develop significantly limited networks knowing that the out-of-network rate will be favorable to them.

Instead of using the HPC to create rates, MHA strongly recommends an approach similar to the state of New York.  In summary, such a model would: 
• Hold patients harmless for emergency services and services that meet the definition of surprise bills
• Insure that the patient pays no more than he or she would have if the services rendered were by an in network provider (i.e. applicable copayments, deductibles, coinsurance).
• Create an independent dispute resolution process for these bills if the provider is unwilling to accept the insurer payment and otherwise has no contract with the health plan
• Pay the provider at the in-network rate if he or she has a contract with the carrier for other products
• Create greater transparency for patients by requiring a disclosure process by hospitals, health plans, physicians and other health care providers.

It is our understanding that the New York law is working as intended and working well for patients, most importantly, but also for providers and carriers. MHA respectfully requests the Senate look to the New York model as a standard for addressing this issue.

Facility Fees 
Based on the language in the bill, it appears that hospitals, health systems and hospital based facilities would be prohibited from charging, billing, or collecting a facility fee for services with a CPT E&M code or other CPT code as determined by DPH.  DPH would also be able to identify additional conditions or factors that would prohibit facility fees from being billed. This law would apply to both commercial insurers and the Group Insurance Commission. It would prohibit facility fees for both on-campus and satellite outpatient services. MHA is concerned that because this proposal goes too far and too deep it poses the unintended consequence of stalling the effort to move care beyond the hospital walls into the community, while at the same time, slashing reimbursement for outpatient care provided in the hospital.

Facility fee, as defined in section 109 of the bill, is “a fee charged or billed by a hospital or health system for outpatient hospital services provided in a hospital-based facility that is intended to compensate the hospital or health system for the operational expenses of the hospital or health system and is separate and distinct from a professional fee.”  

A hospital-based facility is defined as “a facility that is owned or operated, in whole or in part, by a hospital or health system where hospital or professional medical services are provided.”

When taken together, these definitions go far beyond prohibiting facility fees for evaluation and management codes for services provided in off campus settings and would instead encompass any outpatient technical fees charged by any hospital or hospital-based facility, resulting in an inability to recoup the costs of operating an emergency department, radiology facility, laboratory, or outpatient department.  Hospitals would only be able to charge for the professional component, causing enormous financial losses that would not be reconciled through other payment methodologies.  The facility fee proposal is also completely inconsistent with the approach that CMS has established.

This commercial market proposal would serve as a countervailing pressure to state and federal efforts to push more care into the community – particularly as it relates to behavioral health community-based objectives. Facility fees enable hospitals to send specialists to underserved communities and to allow those specialists to provide services without having to pay rent and overhead. Hospital-based clinics may also provide more comprehensive services than a traditional medical office and offer services that are not otherwise available in the community to vulnerable patient populations. Physician offices and ambulatory surgical centers often do not provide services to Medicaid or uninsured patients, while hospital-based clinics accept all patients. Also, patients that receive services in hospital-based clinics are often those that are too sick or complex for treatment in traditional medical offices.

Hospitals also have greater costs than physicians providing the same services in their offices. Hospital-based clinics must comply with much more comprehensive scope of licensing, accreditation, and other regulatory requirements than do traditional medical offices. Unpaid stand-by capacity costs – such as around-the-clock availability of emergency services, emergency back-up for other settings of care, disaster preparedness, and a wide range of staff and equipment – make hospital services more expensive and these costs are spread across all hospitals services, including clinic-based care. And provider fee schedules for the services provided in these facilities already are inadequate as such structures do not build in overhead costs. 

In addition to the obvious financial burden, this bill introduces complicated and unnecessary notification requirements that will result in enormous confusion and generate hundreds of calls to providers and insurers as patients try to understand why they are receiving these notices.  These requirements will add even more administrative cost to the system and could potentially limit the time providers can spend on providing patient care.   

MHA is opposed to the facility fee prohibition included in the Senate bill as it could lead to direct program reductions. Such reductions are painful especially in regions where there are few organizations to provide services to lower-income patients and residents. We would welcome the opportunity to work with the Senate in further reviewing this issue.

Price Transparency
MHA is concerned that section 69 of this legislation continues to put the burden on healthcare providers for issues that are best handled by insurers, including the network status of referred providers and information about the referred provider’s applicable out-of-pocket costs when referring a patient for needed medical care. While it is important to find methods to increase transparency of patient costs, the information that insurers hold, and that providers are expected to provide to their patients on cost and network status, is difficult and time-consuming to obtain – and it is frequently inaccurate when received from the insurer. We are also concerned that the bill amends the existing law to require providers to give every patient this information every time he or she schedules an appointment.  Such a mandate is unsustainable and will add significant administrative costs to an already overburdened system.  Instead, MHA supports the current law that requires providers to assist patients with obtaining cost information upon request as well as additional efforts for insurers to collaborate with providers and patients to ensure that any requested information is disseminated in a timely manner and with the assistance of the insurers that have all of the information regarding contractual status, out of pocket liability, etc.

Readmissions Reduction Benchmark
Reducing and preventing hospital readmissions is a priority for all Massachusetts hospitals.  Since approximately 2009, hospitals have been engaged in a number of state and national initiatives to reduce readmissions within their organizations.  These significant efforts have included the implementation and ongoing evaluation of a portfolio of readmission reduction strategies and measuring progress through different readmission quality measures.  MHA has served as a convener in a number of initiatives to reduce and prevent hospitalizations through engagement with  our hospitals and community providers.  

These initiatives include:
• STAAR (STate Action to Avoid Rehospitalizations)  
• CMS HEN 1.0 & HEN 2.0 (Hospital Engagement Network) 
• MHA SPIA (Statewide Performance Improvement Agenda) 
• CMS HIIN (Hospital Innovation Improvement Network) 
• CHART Programs Phase I and Phase 2

With regards to the establishment of an annual statewide readmissions reduction benchmark, there are many readmission quality measures that hospitals are seeking to incorporate and these measures have been evolving constantly.  Most of the initiatives referenced above that sought to address rates of readmission have used different readmission measures.   MHA is very concerned that there is no description provided in the legislation outlining the criteria that will constitute an “annual statewide readmissions benchmark.”  If the bill is enacted, we would recommend that criteria to establish the annual statewide readmission benchmark be similar to the seven criteria outlined in clause (b) of the new Section 10A established by the law that are proposed to evaluate provider organizations whose rates “are excessive and threaten the ability of the commonwealth to meet the annual readmission benchmark”. In particular, the unique features of a hospital’s patient population and community should be considered (e.g., patient mix, patient population, patients with behavioral health and substance use disorder issues, multiple sociodemographic factors,  patient access, hospital safety net status, and other environmental factors).  

With regards to the proposed 20% reduction of readmission rates between those rates observed between 2017 and 2020, MHA believes that this rate is too aggressive.  It demonstrates no consideration for the improvement efforts achieved already and currently underway, nor the complexity involved in driving down readmission rates.  The CMS HEN 1.0 and 2.0 initiatives reduced their readmission goals from 20% to 12% in the current CMS HIIN because the 20% benchmark could not realistically be achieved.  The 20% reduction proposed in the Senate bill does not appear to account for the provider organizations that have already made significant progress in reducing their readmission rates.  What if there has been incremental improvement, but the benchmark rate has not been met?  Would gradual improvement be acceptable?  Would there be a window of opportunity to improve before an organization is told to submit a performance improvement plan?

As for the civil penalties that are included in this proposal, MHA believes that the inclusion of a civil penalty is punitive and inflammatory.  For many organizations, the proposed civil penalties could be deeper than their current CMS readmissions reduction penalty which providers have been working on diligently to avoid.  If there will be civil penalties, it is imperative that the federal waiver of federal hospital readmissions reduction program at CMS be obtained. 

It also is important to reiterate that hospitals have limited control over readmissions. Community providers play an essential role in the effort and must be part of the solution. Hospitals often have very little control or leverage over the participation of such entities in stimulating change.  MHA believes that all components of the continuum should be incented and share in the responsibility of reducing readmissions. MHA would recommend the development of a “continuum of care program” among hospitals and all community providers in order to best facilitate cooperation in the reduction of readmissions. 

If a new state standard is to be adopted, the Special Committee should be tasked with several considerations, such as setting a differential level of benchmark based on the level of the provider organization’s readmission rate.  We would additionally recommend that the committee seriously factor in sociodemographic factors in readmission rate benchmarks, as it is particularly challenging for providers to maintain low readmission rates with behavioral health patients, substance use disorder patients and Medicaid patients with dual diagnoses of behavioral health and substance use disorders. Additionally, MHA would recommend that, rather than focusing and using a blunt readmission measure, consider using transitions of care process measures to determine progress, including medication reconciliation, medication delivery/funding, booked discharge appointments, and clinical appointments front-loaded soon after discharge from the hospital. We would also recommend that a close eye be kept on other patient quality measures – such as mortality prevention. Readmission rates should not be viewed in isolation. If we make new headway in reducing readmissions, we must ensure it does not come at the expense of other important patient care standards. Finally, MHA would recommend that this legislation provide additional focus on the use of palliative care options and education for providers, patients and families on the benefits of palliative care and providing patients with relief from the symptoms, pain, physical stress, and mental stress of terminal diagnoses in order to improve quality of life for both patients and their families.

Governor’s MassHealth Reform Proposals (Section 133)
Late in the FY2018 budget development process, Governor Baker proposed a number of reforms to address the sustainability of the MassHealth program. The Senate bill does not include the governor’s proposals related to Medicaid.  Instead, the Executive Office of Health and Human Services (EOHHS) is required to provide further detail on its proposed eligibility changes that were incorporated in the recent waiver filing.  MHA supports obtaining further detail on the governor’s proposal. We also share the governor’s perspective that the commonwealth is at a point in time when changes are needed to ensure the sustainability of the MassHealth program. MHA and its member hospitals and healthcare systems have considered the many points regarding the governor’s proposed MassHealth reforms and we believe many aspects including recent modifications of the proposal can serve as the basis for addressing the sustainability of the MassHealth program. We also recognize that the proposal would not be the final product and that improvements would be needed to ensure than any changes to health coverage are affordable and addressed those who may fall through the cracks. MHA looks forward to continuing the dialogue on these proposed reforms with the legislature and the administration.

MassHealth Buy-in Program (Section 123)
The Senate bill would allow EOHHS to create a new Medicaid plan where individuals and employers could buy into Medicaid coverage. Employers would be required to pay for at least 50% of the projected costs and MassHealth would be permitted to require further contributions from employers. Co-payments would be same as Medicaid though benefits could vary. EOHHS is to notify the legislature by October 2018, if it will pursue this option and, if so, develop a plan for doing so, including estimated savings. 

While this new section only permits EOHHS to pursue a Medicaid buy-in plan, MHA has concerns with the concept if it were to be taken up. It is unclear how this program would operate in conjunction with the existing MassHealth Premium Assistance program, which supports individuals eligible for employer coverage. MassHealth enrollees that have employer coverage are currently required to stay on employer coverage and receive premium and out-of-pocket payment support from MassHealth. The proposed program would suggest the opposite approach, allowing employers to shift low-income employees to the MassHealth program. 

MHA supports addressing incentives to keep employees on commercial insurance. We believe the Premium Assistance program should be enhanced and made easier to access.  MHA supports section 92 of the Senate bill which would reestablish requirement that employers report on their coverage offerings to employees thereby allowing MassHealth to better identify its enrollees with access to employer coverage and enroll them in the MassHealth Premium Assistance.  MHA acknowledges that there may be circumstances where such a program could be beneficial to the state when employer coverage is more costly to the state, therefore saving the commonwealth funding.   However we believe the MassHealth Premium Assistance program should be the priority program for those MassHealth individuals with access to employer health coverage.    

The proposed Medicaid buy-in program would allow and likely incentivize employers to move low-income employees to the MassHealth program.  We believe this would be the wrong direction given the already large shift in lives from the commercial market to MassHealth program, all while the state’s overall level of insurance coverage remains steady.   According to EOHHS, MassHealth was the primary insurance coverage for 14% of the Massachusetts population in 2011. This percentage grew significantly to 21% by 2016.  There are now more than 1.78 million Massachusetts residents with MassHealth coverage. The percentage of those with commercial coverage as their primary insurance fell from 65% of the population to 58% during the same time period.  For hospitals, patients with MassHealth primary insurance coverage currently represents 17% of the average hospital patient population, with many hospitals experiencing greater percentages given the disproportionate number of low-income patients they care for.  

MHA would be particularly concerned if there were to be a further shift of people from employer coverage to MassHealth, which would carry with it a substitution of commercial reimbursement rates with Medicaid payment rates. As we have reported frequently, MassHealth hospital reimbursement fails to cover to the cost of providing services to MassHealth patients.  MHA estimates that MassHealth fee-for-service rates only covered 75% of the cost of care in FY2015.  Losses of 25% on a growing population are not sustainable. The legislation seems to acknowledge the effect of a Medicaid buy-in program on provider reimbursement as it states possible savings from the program could be made available for higher provider rates for this particular benefit plan as well as the general sustainability of the MassHealth program. Unfortunately our experience is that MassHealth payment improvements are often short-lived, as was experienced under the 2006 health reform law that called for improvements in hospital and physician payments given the Medicaid expansions.  The fiscal realities of state budget pressures and the MassHealth program have too often been addressed through hospital and provider payment cuts. Because of the immense financial pressures on the program given the lives covered, MassHealth provider reimbursement updates has over the years failed to address the change in labor expenses, new technologies, and other costs to providing quality care to MassHealth patients. 

MassHealth Offered on the Connector Health Insurance Exchange (Section 123)
Section 123 also would allow EOHHS to pursue federal authorization to allow individuals on the Health Connector to purchase MassHealth coverage, including with the support of the federal tax credits, cost-sharing reductions, and other state funding wraps. This has the effect of introducing a “public option” to the exchange which was a controversial concept that had been considered in the development of the Affordable Care Act (ACA), but was not ultimately adopted. 

The concept of a public health insurance option is a thorny issue for providers. Not because another source of coverage is a bad idea, but because government health coverage programs would exacerbate the underpayment problem of providers. The legislature knows very well about the Medicaid underpayment problem. And depending on how this public plan interacts with the private insurance market on a competitive level, reimbursement from private insurance companies to hospitals could also be reduced as they are forced to compete at government prices. Premiums would likely be artificially less and could attract enrollees currently covered by commercial insurance coverage, causing major changes to the small group insurance market and the carriers that participate in it.  Adding a public option to our state’s health insurance exchange based on Medicaid rates will ultimately increase financial hardships and could drastically reduce the services and economic output of hospitals.  

Reducing the Growth in Prescription Drug Spending
Pharmaceutical spending growth has significantly outpaced overall healthcare spending growth in Massachusetts. According to the HPC’s 2016 Cost Trends Report, prescription drug spending remains the largest single contributor to healthcare costs, accounting for approximately one third of per capita cost growth.

According to an October 2016 report presented to the American Hospital Association:
• Drug spending in the hospital inpatient setting is quickly increasing. Growth in annual inpatient drug spending between FY2013 and FY2015 increased on average 23.4%, and on a per admission basis, 38.6%.
• Large and unpredictable increases in the price of drugs used in the inpatient setting significantly affected hospitals’ ability to manage costs within a fixed-price-based payment system.

These types of increases in drug spending are unsustainable for hospitals as well as for patients and place a strain on state health programs that pay for the costs of these pharmaceuticals.

Following the provisions of the state’s healthcare cost control and delivery reform law (Ch. 224), hospitals, physicians and health plans are: held accountable for healthcare costs; must meet healthcare cost growth benchmark targets; and are required to report cost and utilization data to various state agencies. This data, in turn, is readily available to the public. Hospital financial information, in particular, is an open book.

By contrast, there is currently little to no transparency around pharmaceutical costs. MHA supports the provisions in this legislation that would establish a measure of accountability for the pharmaceutical industry and create greater transparency around the factors that contribute to price increases, including provisions that: require pharmaceutical companies to report drug pricing information to CHIA and pharmaceutical company participation in the HPC’s cost trend hearings; require the HPC to provide ‘early warning’ reports on pipeline drugs, generic drugs, or biosimilar drugs that may have a significant impact on state healthcare expenditures once brought to the market, and require pharmaceutical companies to contribute information for these reports; establish an academic detailing program within the HPC to be supported through an assessment on pharmaceutical companies; and assess pharmaceutical companies to support HPC and CHIA oversight and reporting efforts related to pharmaceutical drugs. 

60 Day Provider Opt-out Provision – Section 106
Section 106 of this legislation removes the 60-day opt-out provision for providers in the small group and individual market for new plans which have “separate cost-sharing differential ...applied to shoppable health care services among the network of providers.” Given that such shoppable healthcare services are new, vague and untested products, we are concerned that this change removes the current ability of providers to opt-out of these new insurance plans without further details as to how such plans will be put into effect. 



Aligned Quality Measures Provisions
MHA believes that this legislation takes some positive steps forward in working towards more quality measure alignment that will reduce the measurement and reporting burden for providers. We appreciate the goal to ensure consistency and alignment in the use of quality measures in contracts between payers and providers. Such alignment should make it easier for consumers to make quality comparisons and for providers to focus on quality improvements among a narrower set of measures. MHA believes that a more-level playing field will be created by insurers using a standardized aligned measures set when placing providers into tiers. 

However, we would encourage you to make additional appointments to the aligned measures task force in section 2 of the bill to provide a more balanced perspective since the current task force is too heavily weighted by payers and government payers / representatives and does not provide enough representation for physicians, nurses, pharmacists and electronic health record experts with measurement expertise who can put forth additional perspectives in addition to the current appointee with system expertise. Furthermore, MHA would recommend the consideration of additional language to understand how the decisions of the task force would ultimately be made and how would disagreements on measures would be resolved. Additionally, MHA recommends clarifying language on disagreements between the task force recommendations and the measure set that is ultimately established by the EOHHS Secretary. Lastly, MHA would recommend that additional emphasis in this task force should be used to move away from claims-based measures and focus on clinical quality measures that assist providers to measure the quality of healthcare and how healthcare services improve health outcomes. 

Telemedicine Coverage & Proxy Credentialing
MHA is grateful for the language included in section 99 of the legislation that requires HMOs licensed under Ch. 176G to cover telemedicine services. The inclusion of this coverage recognizes forward progress as we seek coverage parity for telemedicine services. Additionally, we are appreciative for the language in sections 73 & 115 that will align Massachusetts rules with federal standards allowing for a streamlined process for providers to be credentialed to provide telemedicine services by eliminating duplicative credentialing reviews at each site that the provider seeks to offer care through telemedicine. Currently, Massachusetts requires a provider to go through an extensive licensure and credentialing process at each site of care, which requires detailed documentation of Primary Source Verification of each clinician’s education, skills, trainings, and more. This adds to the overall cost and internal resources for each facility that the provider is seeking to provide remote telemedicine services. 

However, while we are grateful that there are initial steps in this legislation to improve access to telemedicine services, we respectfully request that this legislation require coverage parity across all-payers for telemedicine visits on-par with in-person visits. Thirty-three other states require coverage parity for telemedicine services the same as in-person visits across all payers. The Massachusetts Center for Health Information and Analysis (CHIA) has noted that telemedicine is NOT a mandated benefit but a change in modality, stating, “Telemedicine is not a distinct specialty, but is instead the use of interactive telecommunication technologies to deliver a variety of healthcare services to treat many different diseases and conditions.” 

CHIA’s report last session found that the 5-year incremental impact for coverage parity for telemedicine services for commercial payers would be negligible. Additionally, the Millbank Memorial Fund issued a report this summer that urged policymakers to “consider a robust, comprehensive telehealth policy within the state Medicaid program” to eliminate “policy obstacles that  inhibit the full potential of these technologies to achieve the Triple Aim of better health outcomes, improved patient and provider experiences, and increased efficient use of resources to lower costs.”

Furthermore, we respectfully request consideration of the following items related to this issue: 

• Elimination of language that permits insurers to use preauthorization for telemedicine services. In particular, we work very diligently to eliminate barriers in access to care, particularly for behavioral health patients, and preauthorization by insurers is just another barrier to patients receiving care via telemedicine – with no justified reason. 
• Elimination of language in the sections that permit or require insurer coverage for telemedicine services that require telemedicine to conform to the standards of care applicable to the providers’ profession or those provisions in section 73 that imply that the standard of care for telemedicine is different from the standard of care for in-person visits. Such language is unnecessary as the standard of care for telemedicine is not different than the standard of care for in-person visits. 
• A more expansive definition of telemedicine by: i) deleting the word “interactive” from the definition in the bill and inserting language that recognizes both synchronous and asynchronous technologies, including store and forward technologies;  ii) including coverage for oral health in addition to physical and mental health in the telemedicine definition (in particular, since you will have dental therapists created in the bill who are able to utilize telemedicine services as part of their practice in this bill);  and iii) consider including coverage for online adaptive interviews and text-only emails that occur for the purpose of patient management in the context of a pre-existing physician-patient relationship. 
• Ensure that definitions for telemedicine are standardized across all sections in the bill. We would note the definition for telemedicine differs in section 115 than the other sections of the bill. 
• Include language in section 115 similar to the language included in section 73 that directs the respective boards of registration at DPH and the Office of Consumer Affairs and Business Regulation to put forth regulations regarding the appropriate use of telemedicine to provide health care services.

MassPAT Integration in Electronic Health Records
MHA is very appreciative of the language included in section 66 of the bill that that provider entities and their vendors that provide Health Information Exchange Platforms or care management tools are able to access, integrate and maintain MassPAT data for the purposes of compiling and visualizing such data within the electronic health records of a healthcare provider that supports diagnosis, treatment and care coordination. 

Scope of Practice Changes
Dental Therapists 
MHA supports the provisions included in the legislation to authorize dental therapists in the commonwealth. We believe it is a cost-effective way to help close access gaps for a vulnerable population while also easing the growth of MassHealth costs. Dental therapists can serve as important tools to reduce the number of people who go to the emergency department for preventable oral health conditions, helping save critically needed MassHealth resources. These providers work under the supervision of a dentist as they provide preventive and basic restorative care. They are able to bring care directly to people in schools, nursing homes, and other community settings, and are currently providing safe, high-quality preventive and routine restorative care in Minnesota, Alaska, and more than 50 countries around the world.

APRNs 
MHA supports the expansion of scope of practice for all Advanced Practice Registered Nurses– nurse practitioners, certified registered nurse anesthetists, and psychiatric clinical nurse specialists, This legislation allows these APRNs to have pathways to independent practice authority. MHA is supportive of all proposals to require additional post-graduate training prior to full practice authority or independent practice, including some sort of orientation, mentorship, or preceptorship, as well as allowing advanced practice nurses the ability to supervise the process of their fellow nurses toward independent practice authority. 

APRNs should also be held to the same standards of transparency, accountability, and professional responsibility under which physicians practice. This includes Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), public reporting to the Department of Public Health or Board of Registration in Nursing, quality reporting tied to the practitioner, public reporting of medical malpractice awards or settlements, mandated medical malpractice liability policy limits, public reporting of any arrangements between practitioner and the pharmaceutical industry, continuing education requirements, and peer review. And just like physicians, APRNs currently must carry professional liability insurance in order to practice. 

APRNs are guided by specialty-related national and local standards of care, their education and training, as well as by specific regulations governing their scope of practice. Consistent with The Joint Commission recommendations, OPPE is appropriate for all clinicians, including APRNs. There may be gaps in organizational structures supporting OPPE and, where there is appropriate movement towards full practice authority, steps should be taken to ensure that structure and accountability is the same for all licensed independent providers. At the institutional level, scope of practice should be determined by education, training and experience for APRNs just as there is for physicians. It should be expected and verified that an individual’s practice is within his/her education, training, and experience, and that he/she functions within professional boundaries with ongoing professional evaluations.

Pilot Program to Certify Supportive Housing & Affordable Housing Providers with Coordinated Care Teams
MHA strongly supports the language in section 131 of the bill that permits EOHHS to develop a pilot program to certify supportive housing and affordable housing providers to establish coordinated care teams to integrate healthcare for seniors and housing. Such pilot programs can encourage best practices that improve population health for seniors by delivering better care at a lower cost, thereby reducing unnecessary hospital readmissions and emergency room visits. 

Prevention & Wellness Trust Fund (PWTF) 
MHA supports the efforts of the Prevention & Wellness Trust Fund as it is an important partner in successful healthcare transformation, working with both clinical and community partners to address the causes of poor health in community settings and the barriers to successful management of chronic conditions. The PWTF brings evidence-based community health interventions to scale and evaluates their impact. PWTF is providing crucial support to health care providers in their mission to deliver high-quality, value-based care. By addressing the community factors that lead to poor health, PWTF also supports accountable care organizations (ACOs) to take on financial risk by tackling major cost drivers outside the clinical system. We support: the efforts in this legislation to permit the PWTF to accept settlement funds; efforts to provide gap financing in a supplemental budget this fall to address the FY18 shortfall in PWTF funding; a long-term financing source for the PWTF, including FY18 Senate budget that sought to close the tax loophole on flavored cigars to support the PWTF; and use of the excise on the sale of commercial marijuana to support the PWTF. 

Mobile Integrated Health
MHA also supports the intent of this legislation to expand the use of mobile integrated health and community paramedicine to reduce avoidable hospital ED visits, avoidable readmissions, extended ED boarding and unwarranted institutional post-acute care. 

Behavioral Health Urgent Care Licensure
As this legislation focuses on finding patients the right care, at the right time and in the right place by reducing unnecessary emergency department use (and subsequent ED overcrowding with boarded behavioral health patients who are unable to find appropriate care in their communities), MHA supports section 39 of this legislation that that allows the Department of Mental Health to issue a license for a 2-year term for a behavioral health urgent care facility described as a private, county, municipal, or ward of a facility that offers behavioral health urgent care services.

Nurse Licensure Compact
MHA supports efforts to include adoption of the nurse licensure compact in this legislation.  The Nurse Licensure Compact (NLC) allows nurses to have one multistate license in the state where they reside, with the privilege to practice in their home state and all other states that are members of the NLC. We strongly support the NLC because it enhances Massachusetts’ efforts to respond to the changing landscape of health care delivery, permits qualified nurses to care for patients across the health care continuum, allows for better emergency preparedness and more rapid staff response in times of disaster, and enhances access to quality nursing care for all residents of the Commonwealth.

Thank you for the opportunity to offer comments on these important matters. If you have any questions or concerns or require further information, please contact Michael Sroczynski, MHA’s Vice President of Government Advocacy, at (781) 262-6055 or msroczynski@mhalink.org.