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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.

The Public, Press and Unions Support Mandatory Flu Vaccination. Let's Make it Happen.

It's time for everyone to get a flu vaccination, especially those involved in healthcare. Unions including 1199SEIU, the local chapter of the United Healthcare Workers union, are strongly urging their members to get vaccinated against the flu. And the Boston Globe's smart and practical editorial in support of mandatory flu vaccinations for all healthcare workers comes in the wake of the Massachusetts Nurses Association (MNA)'s lawsuit against one hospital trying to carry out the vaccine requirement. Word of the MNA's misguided effort is also garnering strong opposition from members of the general public and physicians, who de-bunk the union leadership's claims of high numbers of adverse events related to flu vaccine, and highlight the fact that nurses who decline flu vaccination and plan to "stay home" if they get sick can infect vulnerable patients prior to falling ill themselves.

MHA and our member hospitals and health systems have long supported mandatory flu vaccination for all healthcare workers. Flu vaccinations are cited by the federal CDC, state Department of Public Health, and local Boston Public Health Commission health officials as the single best preventative action every healthcare worker can take to safeguard the general health of the patients they care for. Getting a flu shot is safe, it's the best way to protect against the influenza virus, and it can prevent unnecessary anxiety and waste of healthcare resources needed to treat more serious illnesses – like Ebola – that have symptoms similar to the flu. Let's ensure all healthcare workers in Massachusetts get vaccinated against influenza this season, and make flu shots mandatory for every healthcare worker who doesn't have a religious or health exemption. It's the right thing to do to protect patients, families, co-workers, our loved ones and ourselves.

Massachusetts hospitals help lead the way in slowing healthcare cost growth

This week's release of reports on both national and statewide healthcare expenditures paints a very clear picture of the success Massachusetts has had in reining in healthcare cost increases.

Just-released National Health Expenditure Data by the Centers for Medicare and Medicaid Services' Office of the Actuary shows that Massachusetts is outpacing the national trend in reducing healthcare spending growth. The U.S. numbers show 3.6% health expenditure growth nationally, which happens to be the same as the healthcare cost growth benchmark the state established.

And the state's Center for Health Information and Analysis (CHIA) issued a report showing that Massachusetts total healthcare expenditure growth rate was just 2.3% – a number well below both the state's healthcare cost growth benchmark and the national growth rate.

While the metrics used in the national and state reports are not identical, they do provide strong evidence that Massachusetts is doing something notable and impressive in the attempt to keep health expenditure growth down.

The report on the national healthcare expenditure trend indicates that while healthcare spending is, indeed, slowing overall in the U.S., it's clear that Massachusetts' sweeping state-specific reforms are paying off.

Massachusetts hospitals have been on the forefront of helping to bend the cost curve. They have embraced alternative payment models; acute care providers, post acutes and physician group practices are collaborating to create integrated care models; and hospitals are carrying out tough, cost-cutting measures – all of which have resulted in very real, very measureable reductions in health expenditure growth. Continuing to bend the cost trend continues to be a challenge, but Massachusetts hospitals are facing that challenge head-on.

Our state also enjoys the highest rate of insured residents in the U.S. – 97% – and this week's CHIA report also showed that from 2012 to 2013 – the most recent data – average premiums and benefit levels remained virtually unchanged.

When healthcare expenditures are growing at a rate below the benchmark set by the state, when average premiums are remaining stable, when a concerted effort is underway to improve the quality of care and ease access, and when Massachusetts outperforms the nation, we should collectively take pride in the increasing value that the Massachusetts healthcare system offers to citizens of the commonwealth.

Lift the smoking age to 21 state-wide

I was thrilled to read in the current issue of CommonWealth Magazine that the city of Salem has joined a growing number of Massachusetts cities and towns to advance public health efforts in their communities by raising the legal age for cigarette purchases to 21*. The Massachusetts Hospital Association (MHA) fully supports making 21 the minimum age for cigarette purchases state-wide, a move that is currently under consideration in New Jersey, even though an earlier effort to do so here in the Bay State was not successful.

Increasing the age at which individuals can buy cigarettes – or any tobacco product – is a common sense way to promote population health. According to the US Surgeon General, almost no one starts smoking after age 25, and almost 90% of smokers started by age 18.

Massachusetts has a strong legacy of leadership in this area – the town of Needham, Massachusetts is widely recognized as the first municipality to boost its smoking age to 21 – back in 2005. The results have been dramatic: the smoking rate in Needham is now less than half the Massachusetts average of 18 percent.

Massachusetts hospitals have also led the way to serve and protect their communities by curbing tobacco use both inside and outside their facility walls.

In 2011, MHA launched a statewide tobacco free initiative and now 76% of our member hospitals completely ban the use of tobacco products anywhere on their campuses. In addition, some hospitals in Massachusetts, as well as MHA, have taken their commitment to public health a step beyond instituting a tobacco-free campus and have adopted tobacco-free hiring policies as well. MHA stopped hiring tobacco users as of January 1, 2011. These facilities have all earned inclusion on MHA's Tobacco-free Honor Roll.

Tobacco use remains the number one cause of preventable death in the nation, and hundreds of millions of dollars are lost each year in lost productivity due to illness and premature death caused by tobacco consumption. Raising the legal purchasing age across Massachusetts would be another good step in the right direction.

* (Along with Needham and Salem, the Massachusetts Municipal Association reports communities that have raised the legal cigarette purchasing age to 21 include Arlington, Ashland, Canton, Dedham, Dover, Hudson, Norwood, Reading, Scituate, Sharon, Wakefield, Wellesley and Winchester; and communities that raised the minimum age to 19 are Brookline, Belmont, Newburyport Sudbury, Walpole, Watertown and Westwood.)

Mass Insight Poll Shows Progress and Work to Be Done

There's some encouraging news as well as a call to action for insurers and providers from the recent public opinion poll conducted by Mass Insight. The poll was the subject of a story in The Boston Globe last weekend.

First, the good news. I was heartened to see that Massachusetts residents are feeling less burdened by healthcare costs compared to last year, and that they continue to support the state and the federal government's healthcare reform laws. MHA has always maintained that persistent efforts by hospitals to become lean and more efficient in providing high-quality care would eventually begin to bend the cost curve downwards. We knew reforming a major part of our state's economy wouldn’t happen overnight but I’m hopeful our reform efforts will continue and consumer confidence will keep rising.

More than 90% of consumers polled said quality of care is more important than anything else, including price, when making healthcare decisions. In this we are all aligned – Massachusetts hospitals have always made quality and patient safety priority #1.

But the Mass Insight poll also found that more than six in 10 respondents said they were not aware of new publicly available sources of information for cost and quality data, and nearly 75% didn't know that insurance companies, hospitals, and physicians must now provide cost information within two days of a consumer request. Payers and providers need to do more to spread the word about pricing information that's now required for many procedures.

Hopefully the Mass Insight poll and its findings will help boost public awareness of these latest transparency requirements as hospitals and other healthcare stakeholders continue to improve patient satisfaction and confidence in our dynamic healthcare system.

Time is Now to Act on Behavioral Health and Federal Healthcare Funding

An impressive collection of healthcare stakeholders have joined with MHA in calling for the state to support two extremely important reform efforts in the upcoming FY 2015 budget.

First, policymakers should address desperately needed behavioral health reform measures.

Five of Massachusetts' largest care provider organizations are jointly calling on the Legislature to support vital behavioral health reform measures in next year's budget. In addition to MHA, the Massachusetts Association of Behavioral Health Systems, Massachusetts Medical Society, Massachusetts College of Emergency Physicians and the Massachusetts Psychiatric Society are urging the adoption of both budgetary action and vital administrative steps needed to bolster timely access to behavioral health care services.

The commonwealth's behavioral health system is broken, and immediate supports are needed to reinforce critical mental health and substance abuse services while we all work toward comprehensive, systemic reform. The multi-step plan advanced by our collective organizations' calls for important investments in community-based placement services, outpatient and community-based diversionary services, and inpatient hospital level services. It also urges the legislature to adopt operational reforms that advance patient access to appropriate services on a timely basis and reduce emergency department delays.

The House version of the budget is expected later this week. To that end, the persistent call for comprehensive reform of the commonwealth's behavioral health system from this broad coalition of healthcare providers, along with many others, is gaining traction throughout the state. In recent weeks, several Democratic gubernatorial candidates and Massachusetts House Speaker Robert DeLeo (D-Winthrop) have all expressed public support for addressing the serious challenges that are currently impeding timely access to behavioral healthcare in Massachusetts.

While thorough and systemic reform may take some time, it's essential that policymakers move forward on some immediate interim steps that will preserve access and advance true parity for behavioral health coverage and services. We hope this growing call from healthcare, public advocacy and civic leaders will result in meaningful improvements for all patients in the very near future.

Second, new federal healthcare funding should be dedicated to its intended purpose – to support both low-income health coverage programs and those who provide the care.

Hospitals, home care providers, physicians, community health centers, advocates for patients and organizations devoted to fighting major diseases are all calling on the state to ensure that the use of federal healthcare funding coming to Massachusetts through the Affordable Care Act (ACA) is set aside to support the funding of Medicaid and other low-income healthcare programs in a transparent manner. Governor Patrick's budget created the "Health Insurance Expansion Fund" to house the enhanced federal Medicaid revenues the state receives and dedicate the funding to "support the financing of health insurance coverage for low-income residents." 

This approach is supported by MHA, Health Care For All; Health Law Advocates; Home Care Alliance of Massachusetts;  Massachusetts League of Community Health Centers;  Massachusetts Association of Behavioral Health Systems;  Massachusetts Law Reform Institute;  American Heart/American Stroke Association;  Massachusetts Medical Society; Massachusetts Health Council; American Cancer Society Cancer Action Network; and Conference of Boston Teaching Hospitals.

This coalition has urged the legislature to carry the Governor's recommendation forward while adding language that increases transparency - so that the amount of revenues in the fund, as well as expected additions and expenditures, are reported regularly – and that explicitly authorizes one of the uses for the funding to be to support those who provide care to Medicaid patients. 

This federal money was intended to shore up and support the important healthcare programs that have been developed under the state's reform effort. By connecting the funding directly to these important programs, the legislature can create true transparency and accountability and help preserve the many collective successes we have achieved since the passage of the first reform efforts back in 2006.

Nurse staffing ratios: still a bad idea after all these years.

The latest event in the nurse staffing ratios and hospital margins/executive compensation ballot issue occurred Monday, when testimony on both proposed legislation and the union's ballot initiatives was heard by the Joint Committee on Healthcare Financing at the State House.

I'm proud to have been among the many members of the hospital and nursing communities who testified in opposition to the proposals. Any and all of them would significantly set back the progress we have made with healthcare reform in Massachusetts.

There can be no doubt that care starts with the actual needs of every patient. And while registered nurses are invaluable members of the caregiving team, that doesn't mean others on the team should not be valued, too. There are cases where more registered nurses can improve care, but not in every case. Sometimes the best patient care calls for the skills and talents of others on the team, as well as other resources including technology. Ratios have been a bad idea for years. They're still a bad idea. And The Boston Herald agrees – the paper issued this editorial in strong opposition to nurse staffing ratios the day of the hearing.

There's also a proposal before the committee that calls for caps on hospital operating margins and executive compensation. This proposal certainly appears to be more about politics than sound policy. Under state and federal reform, hospital financials are already transparent. The "transparency" provisions called for in this proposal are duplicative. As for the proposed caps – operating margins alone are inadequate measures of hospital financial well-being. They are snapshots that often fail to illustrate true fiscal health. Operating margins may be positive one year and negative the next, and they do not reflect the debt a hospital may be carrying or its difficulties in accessing capital needed for critical investment in facilities and equipment. As the saying goes, a hospital will have an operating margin until the day it closes. This week's announcement by North Adams Regional Hospital that it's shuttering its doors at the end of this week is stark proof of that.

Simply put, the proposals under review by the Joint Committee on Healthcare Financing would be harmful to the state's healthcare system and patient care. For a state known for innovation and progressive thinking, adopting or advancing any of these proposals would be a clear step back.

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