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Voices in Healthcare

Looking Back, Looking Forward on the Massachusetts Healthcare Front

As 2016 kicks off in earnest with a traditional New England cold front, MHA's member hospitals, health systems, physician groups and caregivers can reflect on the many accomplishments and challenges we have faced in the past year, and anticipate our ongoing and future efforts to make healthcare even more safe, high-quality and cost-effective in the future.

The latest Health Policy Commission (HPC) 2015 Cost Trends Report provides an important look at our state’s healthcare landscape. It reveals progress and challenges across the board, but I was particularly pleased to note some of the outstanding progress Massachusetts hospitals have made in bending the cost increase trend.

The HPC report specifically notes that commercial hospital and physician spending grew just 1% per capita in 2014, significantly below the state's cost growth benchmark of 3.6%.

Hospitals and physician groups are leading the way in reducing the growth in healthcare spending, even in the face of government underpayment for care provided to those enrolled in state and federal healthcare programs like Medicare and MassHealth. They deserve recognition for these efforts.

This continued reduction in the cost trend for hospital-related services is the result of numerous proactive efforts large and small. I believe the best way to advance this success is to escalate the movement to alternative payment models.

More transparency and a rigorous conversation are also in order regarding prescription drug prices as a driver of healthcare trends. Providers are limited in what they can do to mitigate cost escalation in this area, but it is clear that reducing total healthcare spending requires attention to all components of the overall cost trend. Just think what the cost trend would have looked like had we not had such significant increases in drug costs.

To use a cold-weather analogy, we have to be careful not to focus too much on individual threads when we should be looking at the entire sweater. The sooner the market can move to alternative payment in all delivery settings, the sooner we will get more comprehensive connected care, better quality and, as a byproduct, lower expenditures.

Looking ahead, there are two particular challenges that will engage hospitals and care providers in the New Year.

First is an onerous ballot initiative that seeks to regulate hospital pricing at the ballot box. This proposal is seriously flawed, overly simplistic and could potentially move Massachusetts healthcare reform in the wrong direction after years of real progress.

MHA's board of trustees, which represents hospitals of all types and sizes across the commonwealth, voted unanimously to oppose this "regulation from the ballot box" proposal. We already tried healthcare price regulation and ultimately rejected it as inflexible and fraught with unintended consequences. Instead we have moved to a hybrid system that involves both government and the market; there is great wisdom in having a balanced approach. We should be extremely cautious about attempts to essentially go back to the past to adopt a system that couldn't adapt to the comparatively simple healthcare system of the 1980s. Given the rapidly changing healthcare payment system of today, we need a different approach.

Current reforms—namely the healthcare cost containment law, Chapter 224 – haven't been fully implemented. Alternative payment models are expanding, there is greater integration of care, healthcare information technology is improving, and greater transparency will bring information to the public and policy makers that will promote better care and efficiency. The status quo isn't perfect, but it has helped drive progress at a macro level. Meanwhile, concerns have been raised about how the market system has been operating and the resulting variation in prices for individual providers. Such issues can be examined and resolved without engaging in the charged environment of a political campaign.

Perhaps most importantly, the ballot initiative doesn't address one of the greatest contributors to hospitals' financial challenges: low government reimbursement. For hospitals that are under financial stress, a common denominator is government underpayment for the cost of care. For the many hospitals that are overwhelmingly reliant upon government reimbursement, the real solution is adequate government reimbursement.

The second long-term challenge is confronting and defeating the opioid addiction crisis in our commonwealth.

The hospital community appreciates the leadership that the Governor, House Speaker, and Senate President have brought to this crisis. We are committed to promoting proposals that recognize that any solution has to call for action from all the key stakeholders: providers, insurers, government, law enforcement, and communities.

As hospitals we recognize our special responsibility to identify and implement solutions. The priority remains our patients. Hospitals must effectively use their resources and skills to both prevent and treat substance use disorders. Hospitals should be accountable for the care they provide, but they must also be allowed to use their best clinical judgment to meet the needs of each patient suffering from, or in danger of suffering from, an addiction, without disadvantaging other patients who have pressing medical needs such as managing chronic pain.

Hospitals are open to changing how addiction is addressed as a matter of urgent public concern. But any limitations on the clinical judgment of physicians should be done in a way that recognizes that caring for patients, especially in an emergency situation, is not a simple "either or" decision. Not all patients and situations are equal, therefore some level of professional discretion is necessary and in the best interest of patients; but at the same time there should be transparency and accountability to address any individual providers or circumstances that may be contributing to the problem.

And collectively we must work to ensure that preventive resources are widely available across the state so that there is less need to turn to hospital emergency departments to treat addictions. Rather than being housed in hospital emergency departments, those in need of on-going care and support should have a place to turn to in their local communities.

MHA has been working for months with member hospitals across the state to galvanize efforts within the hospital community to address the opioid crisis. Our Task Force on Substance Use Disorder Prevention and Treatment has already produced a first-in-the-nation standardized guidance for hospital Emergency Departments and is now working on guidance for other hospital departments and facilities.  Progress is being made, but so much more needs to be done before the affliction of substance abuse is no longer ruining and ending lives within our communities.

We see the bills now working their way through the state legislature as further opportunities to collaborate and identify creative, compassionate, and flexible solutions to address this intractable problem. We are all united in our common goal to help, in the most effective manner, patients and families suffering through this terrible crisis.

May 2016 be the year we achieve these goals.

A Quality Move by BCBSMA

The announcement this week by Blue Cross Blue Shield of Massachusetts that they will provide some of the nation's most comprehensive benefits for end-of-life discussions and care is an excellent move that appropriately focuses on both quality of care and quality of life across the board.

It is a compassionate and common sense approach that helps patients first and foremost – as it should. Improved access to information and support surrounding end-of-life can also have the added benefit of helping to manage costs when hospital care may not be needed or desired and other options could serve patients better.

While Medicare will begin covering end-of-life discussions between physicians and patients in 2016, I believe open and honest conversations about a person's end-of-life wishes and care preferences should ideally begin well before age 65, let alone before a person becomes seriously ill. Expanding end-of-life benefits to all patients, regardless of their age, is the right approach.

MHA applauds the Blue Cross effort, and hopes that other insurers state- and nation-wide follow BCBSMA’s great example.

A nurses' union's imprudent mandatory staffing effort returns

Earlier this week, the Massachusetts state legislature's Joint Committee on Public Health heard – yet again – testimony on a nursing union's misguided legislation to mandate one-size-fits-all nurse staffing ratios. And as we've done for the past 15 years, MHA, our member hospitals and the Organization of Nurse Leaders of MA/RI/NH/CT (ONL) voiced strong opposition to mandated nurse staffing ratios in Massachusetts.

This editorial in the Boston Herald gives a good overview of the hearing and the shortcomings of the union’s unwise proposal.

The union has it wrong on every level. The importance of registered nurses does not need to be artificially inflated by mandating the use of registered nurses when patient care does not require it. Respecting the professionalism of registered nurses does not mean that legislators remove bedside nurses' discretion to determine what staffing levels meet a patient's needs. Supporting registered nurses does not mean that the job security of other dedicated members of the caregiving team and those who support the teams must be threatened.

There is a reason that in the 20 years since a California nurses union campaigned to pass a registered nurse staffing mandate that not one other state in the country has adopted such a radical approach: it doesn't work. It is not controversial to say that providing care to patients in a hospital setting is as complex as it is important. It is too important and complex to be done by a fixed formula.

When you look closely at what the union proposes in their legislation, they prove that their proposal is fatally flawed. In California, their law dictates that the staffing levels in hospital medical-surgical units be 5 patients to one nurse. But in Massachusetts they would dictate that the ratio in such units be 4 to 1. At the national level, the union calls for telemetry units to be staffed at a 1:3 ratio, but in Massachusetts the union would mandate that telemetry units be staffed at a 1:4 level. So it is evident that by their own tacit admission there is no single staffing ratio that can apply to all patients in similar units regardless of the severity of a patient's illness, the experience and education of nurses, and the composition of the caregiving team supported by other medical resources.

The union also claims that there are many studies that support their position. I encourage everyone to look at those studies. We have and so has ONL, and we found that none of the studies support the union's claims. Not one. The studies point out that nursing care is important. We couldn't agree more. They demonstrate that variation in nursing care and other factors can make a positive impact on patient care. We agree. But what they don't say is that there is a predetermined, set staffing formula that meets the needs of every patient in a unit.

Massachusetts is in the forefront of ensuring that every person has access to high quality care that is effective and affordable. We are making great strides towards achieving those goals, and hospitals are fully engaged in that effort. That is why hospitals increasingly are paid not simply to provide services, but by determining that the care they provide produces good outcomes for our patients. And we are in the midst of a transformation where caregivers are increasingly working to keep patients healthy so that they do not need to be in hospitals. What the union proposes runs counter to what healthcare reform is all about in Massachusetts.

On average, 75% of hospital costs are used to pay for those who work in hospitals. The largest portion of hospitals workers are nurses and Massachusetts nurses are the highest paid in the country, except for one state – California. So it's easy to understand that increasing the number of nurses in hospitals without tying such increases to the actual care needs of patients will have serious implication for all the others who work in hospitals. It will even drive up the cost of nurses in non-hospitals settings such as home healthcare and community health centers.

Despite union claims to the contrary, the quality of care in Massachusetts is good. In fact, on the critical measures of Patient Care experience and Mortality measures, Massachusetts out-performs California. If the union's mandated staffing formula could deliver quality care as they claim, then after more than 20 years of experience, California should be leading the entire country in quality care measures – but it isn't.

Is there more we can do? Absolutely. That is why MHA and ONL have filed legislation to increase transparency about not only staffing, but also patient outcomes. And because research shows that nursing education is a critical component in improving care, the legislation promotes an increase in the number of registered nurses with 4-year college education. This legislation focuses on the needs of patients and respects the professional status of nurses. It’s the right focus.

So we're achieving a great deal with more to do. And there are different ways to achieve improvement. But the evidence is clear that government – as opposed to nurses and doctors by the bedside - making staffing decisions is not an answer, it's a problem.

All hands on deck to combat opioid misuse and addiction

I am quite heartened by a spate of recent progress made by Massachusetts state and federal lawmakers to address and ease our nation's opioid misuse and addiction crisis.

On Sept.10th, the Massachusetts Senate's Special Committee on Addiction Prevention, Treatment & Recovery Options released a comprehensive report and accompanying legislative recommendations. The day before, two members of our Congressional delegation, Rep. Katherine Clark and Rep. Joe Kennedy III each advanced extremely thoughtful pieces of legislation to target specific concerns stemming from opioid use disorders. MHA strongly supports their passage.

These efforts build upon the work of senior Massachusetts Congressman Sen. Edward Markey, who has been one of the first, strongest and most sustained voices in the national call to address the tragedy of substance use disorders and addiction, which have devastated or destroyed the lives of so many Americans.

The Massachusetts hospital and health system community is a dedicated partner in the campaign to eliminate the misuse of opiates, both in the commonwealth and nationwide. For more than a year, MHA and our care provider members have taken a leading role in the effort to prevent and successfully treat opioid misuse and addiction in Massachusetts through MHA's Substance Use Disorder Prevention and Treatment Task Force, which is focused on working with our providers to find alternatives to prescribing certain opioids depending on the patient's condition as well as improving the communication between providers and their patients about the use and disposal of opioids. Our work is ongoing, and we believe the best approach to this complex and insidious problem is multi-faceted. There are a variety of steps that must be taken, both on the public policy front and through culture change within the healthcare community. MHA's task force is facilitating both needed changes and vital new policies.

The efforts of our state and federal elected leaders complement and enhance MHA's endeavors, as well as our collaborations with other state government leaders, public health organizations and advocates, and community leaders. It is encouraging to see this collaborative "all hands on deck" approach in action.

MHA applauds all this hard work on behalf of our most vulnerable residents, and proudly puts our shoulder to the wheel. We look forward to working with the state legislature, Congress, and leaders throughout the community to enact meaningful tactics to address the ongoing crisis.

More Opportunities to Join Massachusetts’ Campaign Against Tobacco

Efforts to oppose tobacco use and promotion both nationally and in Massachusetts have me feeling increasingly hopeful that we will indeed "make smoking history" sooner rather than later. Last week's decision by CVS to withdraw from the US Chamber of Commerce in the wake of revelations that the national chamber lobbies heavily against anti-smoking laws, and the strong condemnation of the US Chamber’s position by Congressional leaders including Sen. Elizabeth Warren, as well as by the Greater Boston Chamber of Commerce, are breaths of fresh air in the battle against tobacco use.

More Massachusetts cities and towns are working to restrict the availability of tobacco products as well. Natick increased the age at which individuals can purchase tobacco to 21 last April, and Arlington became the most recent municipality to boost the minimum age for tobacco sales to 21 just a couple of weeks ago. Currently, more than 50 Massachusetts municipalities have a 21-year-old age requirement to buy tobacco products. In addition, Attorney General Maura Healey has proposed regulations that will ban the sale of e-cigarettes to minors and regulate them the same way traditional cigarettes are controlled.

All of these measures are a good start, but the health costs of tobacco use are still devastating, with Massachusetts suffering an estimated $6 billion every year in direct healthcare costs and lost productivity due to tobacco-related illness and death. But a hearing before the Massachusetts Legislature’s Joint Committee on Public Health on Tuesday, July 14 will consider testimony on several important tobacco prevention bills that can further improve the state of public health in Massachusetts. The hearing will take begin at 1pm in Room B2 at the State House.

Among the bills under consideration at the hearing are several that are MHA priorities. These include SB1137/HB1954, which prohibits the sale of tobacco products at health care facilities; HB2050/SB1119, a bill that would prohibit the sale of nicotine delivery products such as e-cigarettes, in addition to other tobacco products, to anyone under age 18; and HB2021, which would restrict the sale of tobacco products to children under the age of 21, including the sale of e-cigarettes.

Massachusetts hospitals have historically adhered to the policy against tobacco sales at healthcare facilities on a voluntary basis, and in fact, over 76% of MHA member hospitals have completely tobacco-free campuses. Member hospitals generally also include e-cigarettes in their anti-tobacco policies.

Here at MHA, we take our mandate to promote public health quite seriously, particularly when it comes to combatting the dangers of tobacco. We haven't hired tobacco users since 2011, and several of our member hospitals have joined MHA in establishing employment practices that screen for tobacco use. Our building and grounds are completely tobacco-free, and I recently had the honor of being recognized by Tobacco Free Mass for my work to promote this vitally important public health effort. MHA has submitted testimony in support of SB1137/HB1954, HB2050/SB1119 and HB2021, and will continue to advocate strongly for these and other efforts to improve public health for all Massachusetts residents.

AG's Report Shines a Needed Light on Behavioral Health Problems

Attorney General Maura Healey's new report on the intersection of behavioral health services and healthcare reform makes important observations regarding Massachusetts' ongoing efforts to improve both our healthcare delivery and payment systems. It is also noteworthy that the report's findings and recommendations are in-step with MHA's positions and advocacy efforts related to behavioral health parity.

AG Healey and her staff should be commended for identifying some longstanding flaws in our healthcare system that make it more difficult to provide Massachusetts residents with high quality and efficient behavioral health services. These include a lack of important behavioral health related data, inadequate financial incentives to promote coordinated care, and historically low behavioral health reimbursement rates.

MHA has priority legislation (HB905, Act Expanding Coverage and Access to Behavioral Health Services, sponsored by Rep. Liz Malia (D-Jamaica Plain) and Sen. John F. Keenan (D-Quincy)) that advances numerous administrative fixes to minimize delays for patient access to behavioral health services. The bill also proposes innovative strategies to enhance care for difficult-to-place patients, and helps ensure appropriate resources are invested in the system.

Much of what we're proposing is common sense, but it is far from being common practice. It's gratifying to see other healthcare stakeholders – including the Attorney General – making similar findings. One of the chief benefits of the AG's report is that it brings greater attention to a subject that is in urgent need of solutions. Behavioral health is a vital component of overall health, and it's beyond time we gave it equal support under the law, as well as adequate systems and resources to provide the care that is necessary. Any vision of reforming the healthcare system that doesn't include addressing the shortcomings of the behavioral health system is indeed short-sighted.

Behavioral Health Parity: It's Time.

MHA is a longtime champion of behavioral health parity – treating mental health and substance abuse conditions on par with physical injuries and illnesses. This is not a new effort, but it sometimes struggles for broader visibility, both in Massachusetts and across the country. I'd like to take advantage of the fact that May is National Mental Health Month to highlight a bill now moving through the state legislature that MHA and our member hospitals strongly support, and that I believe will help repair our broken behavioral health system.

Yes, broken. Right now, too many patients experiencing behavioral health issues do not have adequate access to non-emergency treatment for their conditions. And once their situations escalate to crisis-level, these individuals are subject to administrative delays and barriers that range from notice/authorization requirements to a lack of available inpatient beds for adults and adolescents that can mean a patient must "board" in a hospital emergency room to await treatment – sometimes for days. It would be unthinkable to make a patient with a broken bone wait days for treatment. The same should be true of patients needing behavioral healthcare.

HB905, "An Act Expanding Coverage and Access to Behavioral Health Services" is a big step in the right direction. Developed in concert with a broad array of behavioral health providers and sponsored by Rep. Elizabeth Malia (D-Jamaica Plain) and Sen. John Keenan (D - Quincy), it is a sweeping bill that would, among other things:

  • Implement parity provisions that remove certain prior authorization requirements for inpatient mental health services provided to patients enrolled in Medicaid and private insurance plans;
  • Clarify that an Emergency Department (ED) physician has the authority to assess if a patient has the mental capacity to enter into an inpatient mental health setting;
  • Expand community-based crisis stabilization services to help care for patients, as an alternative to coming to hospital EDs, which would help reduce emergency department boarding;
  • Require insurers to develop access to a live person, 24-7-365, to help providers find a placement for the plan's patients when they are waiting in the ED with no available inpatient behavioral health placement options;
  • Direct all insurers (including Medicaid) to pay providers at the inpatient contracted rate for each 24-hour period that a patient remains boarded in the ER, which could spur insurers to help find placements;
  • Fund the development of a specific adolescent behavioral health unit; and
  • Expand private insurer coverage for community-based behavioral health services for children and adolescents that are currently only covered by Medicaid through the Children’s Behavioral Health Initiative.

While it's true that healthcare reform is a never ending process, it is also true that behavioral healthcare in the commonwealth is the biggest unmet challenge in our rapidly evolving health system. This comprehensive bill would take specific needed steps to help move the system more closely toward true parity for behavioral health patients. True parity is about equality, fairness, and respect. It is what all patients deserve and too many behavioral health patients are still waiting to receive.

The AG's bold move against e-cigs

Massachusetts Attorney General Maura Healey proposed a statewide ban of the sale of e-cigarettes to individuals under the age of 18. AG Healey proposes to standardize e-cigarette sale practices across Massachusetts – where, incidentally, more than 43 percent of the cities and towns already have age limitations in place for the sale of e-cigs. Even with this broad adoption, Massachusetts is behind the curve on prohibiting e-cig sales to minors. Forty-two other states have already banned selling the battery-powered nicotine delivery devices to under-age residents. AG Healey is wisely and correctly urging the commonwealth to adopt a measure that can help limit future nicotine addiction, reduce conventional tobacco use, and lead to a healthier population overall.

MHA and our member hospitals have been leading the way in eliminating cigarettes and other tobacco products from their campuses since 2011. Under the Massachusetts Hospital Association (MHA)’s HEALING Inside and Out: Tobacco-Free Hospitals initiative, more than 76% of member hospitals now completely ban the use of tobacco products anywhere on their campuses. These facilities have earned inclusion on MHA's Tobacco-free Honor Roll, and have self-reported they ban the use of tobacco across their campus including parking lots and garages, with absolutely no exceptions. Tobacco-Free Hospitals also have policies which eliminate employee, patient and visitor exposure to tobacco smoke and assist employees and patients to quit smoking. MHA and six of our member hospitals have taken this effort one step further – we no longer hire tobacco users.

The jury is still out on whether e-cigarettes are better, worse or similar to conventional cigarettes in terms of overall public health risks. But the fact remains that e-cigs promote nicotine addiction, and our elected officials should move to prohibit their sale to the young people of Massachusetts.

A time to reflect on patient care

Patient safety is always paramount at Massachusetts hospitals, but as we mark National Patient Safety Week March 8 -15th, it's an opportunity to reflect on the many ways our hospitals are constantly working to provide even better care.

Sometimes, the best patient care can be a procedure or intervention that doesn't take place at all, a concept that is central to the Choosing Wisely Massachusetts campaign being led by Massachusetts Health Quality Partners (MHQP). MHA is both a proud member of MHQP and a participating organization in the Choosing Wisely Massachusetts public awareness effort.

As Massachusetts moves away from fee-for-service care delivery and toward more comprehensive population health management, the change offers an important opportunity to encourage dialogue between caregivers and patients about the long-held misconception that "more" care equals "better" care.

Choosing Wisely Massachusetts brings together more than 20 Bay State healthcare organizations and agencies to focus on patient engagement and evidence-based care recommendations that patients can discuss with their doctors. The current Choosing Wisely effort encourages patients to talk with their physicians about whether diagnostic imaging in the treatment of their lower back pain or persistent headaches is appropriate. MHQP's review of the latest available clinical research showed that about 20% of the imaging tests ordered by Massachusetts primary care physician practices are not indicated.

MHA's Vice President for Clinical Integration, Steven Defossez, M.D., is also a practicing radiologist and MRI specialist. According to Steve:

"People suffering from lower back pain or headaches want to know what's going on and they want relief. Cross-sectional imaging tests are powerful tools, which when applied thoughtfully can result in accurate diagnoses and formation of appropriate care plans. It's not surprising that patients with these conditions often look to an MRI or CT scan for answers. However, diagnostic imaging may not always be the best option. Over-utilization of diagnostic imaging is wasteful at best and may actually be harmful. It's important for patients to work collaboratively with their caregivers and make sure they're following evidence-based best practices to get the best possible outcome."

I encourage everyone to visit the Choosing Wisely Massachusetts website, to make note of the wealth of important information there, and to begin or continue the discussions that will undoubtedly arise with family, loved ones, and especially caregivers. This week and every day – Massachusetts hospitals stand ready to help our patients choose wisely.

Giving Thanks… and Aspiring to Do Even Better

The holiday season is officially underway, and we have a lot to be grateful for in Massachusetts, particularly when it comes to healthcare.

More residents have health insurance here than in any other state, with 97% of the population covered. In addition, healthcare cost increases are lower in Massachusetts – at 2.3% coming in well below even the ambitious 3.6% benchmark set by the state in our landmark 2012 healthcare payment and delivery reform law, Ch. 224. Healthcare insurance premiums are also stable, with overall premiums for next year increasing 3.1% and for those shopping on the Massachusetts Health Connector, an even more moderate increase of 1.6% over last year’s rates on average.

Perhaps most importantly, healthcare quality remains outstanding in Massachusetts. We are ranked second in the nation by the prestigious Commonwealth Fund on their Scorecard on State Health System Performance, and placed first in the US for access and prevention/treatment indicators.

Yet there is still more to be done. Massachusetts has appropriately started to move away from fee-for-service payment models for care and toward more patient- and quality-centered standards. Initial research has shown this "global payment" approach can both save money and improve care, and we are fortunate that this movement is being embraced by virtually every acute and even some specialty hospitals, health systems and growing number of physician groups. But in the last year we've stalled in our adoption of such risk-bearing contracts, and are now down nearly 1% from a high of 35.2% in 2012. We still need increased employer and consumer engagement in healthcare, and it is difficult to get healthy individuals to pay attention to non-sexy topics like preventive health and evidence-based medicine – though we are starting to see some movement in this arena thanks to increased price transparency here in Massachusetts and through changes in benefit design.

I believe the way to continue to improve our entire healthcare system in Massachusetts is through alignment – of hospitals, health systems, physicians and other providers throughout the continuum of care, along with the payment mechanisms of government and other insurers. It really will "take a village." While we should appreciate all that we have, our healthcare reform work is not done. Massachusetts hospitals, health systems and provider partners aspire to achieve better outcomes in quality of care; that pursuit will lead to lower costs as well and for both reasons is of utmost priority as we head into the new year.

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