The Massachusetts hospital community continues to take important steps to address the opioid crisis affecting Massachusetts and the U.S.

Last week, MHA, working with Tufts Medical Center and various clinicians and operational staff within member facilities, released two documents to assist hospitals in addressing a trend of patients misusing opioids within their facilities. Hospitals have reported that patients being treated for substance use disorder are frequently reverting to opioid use during treatment, often assisted by friends and family who bring non-prescribed opioids into the hospital.

The documents – Inpatient Opioid Misuse Prevention Guidelines and Patient and Family Agreement on Opioids – were authored by Deeb Salem, M.D., Tufts Medical Center’s co-interim CEO and chair of the Department of Medicine at Tufts University School of Medicine; Steven Defossez, M.D., MHA’s Vice President for Clinical Integration; Tufts University School of Medicine student Ifeanyi D. Chinedozi; and Tufts University student Megan V. Fernandez, now at University of Massachusetts Medical School.

The prevention guidelines identify clinical practices and operational policies to optimize patient care, and include among other strategies: screening for opioid use disorder; prevention of acute withdrawal through medication assisted therapy; management of acute pain for those suffering from chronic opioid use; preventing patients and visitors from bringing opioids into a hospital; and care coordination for patients refusing to follow zero-tolerance of opioid misuse.

The patient and family agreement documents are consent forms spelling out the steps the hospital’s care team will take to assist patients on their road to recovery, and the obligations of patients, family members, and visitors to help achieve those goals.

“Our nation’s opioid epidemic has become the great equalizer. No zip code, no income level, no background, is immune from its devastating reach.  It will take all of our best and collective efforts to solve this complex problem that has already taken far too many lives. Hospitals on the front lines of this battle are committed to using our resources and expertise to develop and effect solutions.  We’ve led the way on implementing prescription limits, which is beginning to make a significant difference in reducing access to opioids,” said Steve Walsh, president & CEO of MHA. “We are gravely concerned knowing that addicted patients bring heroin or non-prescribed opioids with them to the hospital, or try to obtain illegal drugs during their stay.  Today, we announce a new component in our initiative to prevent unlawful and dangerous opioid use within hospitals. We are working in tandem with our member hospitals and other concerned groups to launch inpatient guidelines and a patient/family agreement to provide a first-in-the-nation, comprehensive, statewide framework to screen, manage, and treat patients with Opioid Use Disorder.”

DPH’s quarterly opioid report was released last Friday showing that for the first three months of 2018 there were approximately 474 confirmed or estimated deaths from opioids in Massachusetts. This is below the 2017 three-month total of 501 deaths. 2017 was the first year in the past seven in which the death rate for opioids decreased in Massachusetts.

DPH noted in a clinical advisory that between 2014 and 2017 there was an upward trend in opioid-related deaths where cocaine was also present. DPH says that was either because individuals knowingly used cocaine with opioids or they were using cocaine and were unknowingly exposed to highly potent fentanyl that was present in the cocaine.

In addition to the clinical and operational steps Massachusetts hospitals are taking to fight opioid use disorder, the research they are conducting is helping to inform national action on the issue.

Boston Medical Center’s Grayken Center for Addiction last week had an important study published in Annals of Internal Medicine detailing how the use of two FDA-approved medications – methadone and buprenorphine – can save lives. Specifically, those who survived an opioid overdose had a greater chance of staying alive if they receive methadone or buprenorphine. Those who don’t receive these medications in their continuing treatment after an overdose have a much greater chance of dying, according to the study.

Unfortunately, the authors found, only about three of 10 opioid overdose survivors receive methadone and buprenorphine. The authors suggest potential care delivery reforms to improve access to effective treatment. These include getting more providers in emergency and inpatient settings trained and waivered to prescribe these medications, as well as having better access to linking these patients with primary care physicians trained to care for them.

The Massachusetts Supreme Judicial Court ruled last Monday that an initiative petition imposing inflexible nurse staffing ratios on all hospitals would proceed to the ballot. 

The Coalition to Protect Patient Safety had argued that the proposed ballot question from a nursing union representing less than one-quarter of the state’s RNs was drafted incorrectly and should be disallowed.  (The SJC also ruled that the Attorney General was correct in refusing to certify another ballot question related to staffing ratios.)

The Coalition said of the decision, “It’s unfortunate that any version of this measure passed technical legal muster, but we understand that the justices’ hands were tied and note their reasoning, ‘That the full consequences of the proposed act would be fleshed out after its passage does not render its form improper.’  Our campaign is dedicated to presenting the full consequences of this question. Nurses delivering care across the state have reviewed the ‘mandatory and inflexible’ ratios in this ballot initiative and their negative impacts on the way nurses deliver care. They are joining our effort to defeat this proposal because rigid, government-mandated staffing ratios take decision making away from nurses and put in it the hands of the government at a price tag of more than $1 billion annually, a cost everyone will share in the form of higher insurance premiums and taxes. We look forward to sharing the perspective of nurses with the voters on why this is bad for patients, bad for nurses, and bad for hospitals in Massachusetts.”

Following last week’s Massachusetts House vote on a complex healthcare bill, attention now turns to an as-yet-unannounced conference committee that will attempt to resolve differences between the House bill and legislation from the Senate passed last November.

A core pillar of both bills is the recognition that some community hospitals are in need of financial help.  Lacking the bargaining power of bigger systems and usually serving a larger percentage of poorer patients enrolled in Medicaid, these hospitals made a compelling case to both the House and Senate that they needed relief.

The House created funding support through a revised Community Hospital Reinvestment Trust Fund, weighted toward the lowest paid hospitals, funded by a broad base of assessments on hospitals, insurers, urgent care centers and unaffiliated clinics, and increased professional licensure fees. This was coupled with Division of Insurance review of warranted/unwarranted factors of price variation as part of the rate approval process, and a connected Performance Improvement Plan process overseen by the Health Policy Commission.

In his comments on the House floor, House Majority Leader Ron Mariano (D-Quincy) explained the rationale behind the hospital-relief component of the bill, saying, “[W]e are forced to take some extraordinary measures to ensure there is a minimum reimbursement rate for these hospitals in our gateway cities, since they are the economic engines of these cities.” Citing the changing care models now underway in Massachusetts, Mariano said, “It is our hope that over the three years of this bill, the dynamic in healthcare will change and I'm not going to say we won't be here three years from now making adjustments. But we will know we put these hospitals on a good footing. Probably the most important thing we do in this bill is to solidify these important hospitals.”

Hospital financials are publicly reported and the ongoing precarious financial condition of many facilities in the commonwealth is evident.   In 2016, for example, 14 hospitals in Massachusetts had negative operating margins. An independent analysis determined earlier this year that if a proposed ballot question to impose government-mandated nurse staffing ratios were to pass, its $1.3 billion cost would drive an additional 25 hospitals into the red.

The Department of Labor last week released a final rule that allows for the expansion of Association Health Plans (AHPs), a move that MHA and other healthcare interests in the state had opposed strongly earlier this year, and one that Massachusetts Attorney General Maura Healey says is illegal and will lead to her filing suit against the Trump Administration.

The final rule expands the definition of “employer” in the AHP regulations, making it easier for employers to band together even if they are not in the same industry but merely operate in a common geographic area. By forming AHPs the employers can bypass Affordable Care Act rules relating to essential health benefits, pre-existing condition protection, and regulations concerning premium ratings and co-payment limits.

In March, MHA joined the Mass. Medical Society, Health Care for All, the Mass. Association of Health Plans, and Blue Cross Blue Shield of Mass. in a letter urging the Department of Labor to reject the proposed rule change.

The hospital, physician, insurer, and consumer groups wrote: “If this rule is finalized in its current form, it is likely that small businesses with younger, healthier risk will move to establish AHPs, while groups employing individuals with older and sicker workers will remain in our merged market. The proposed expansion of the definition of employer to include working owners would also incentivize individuals, who would normally purchase coverage in the merged market, to migrate to AHPs, leaving the merged market concentrated with unhealthy risk. As the better risk moves out of the merged market and into AHPs, premium rates for those businesses that remain will increase, making it more difficult for employers and individuals to maintain coverage.”

The Trump Administration claimed the changes would provide more choice to consumers. Opponents of the president’s clearly stated pledge to dismantle “Obamacare,” said greater choice comes with fewer consumer protections.  In joining New York’s Attorney General Barbara Underwood in announcing a lawsuit, AG Healey said the AHP expansions “will invite fraud, mismanagement, and deception – and, as we’ve made clear, will do nothing to help ease the real healthcare challenges facing Americans. We believe the rule, as proposed, is unlawful and would lead to fewer critical consumer health protections.”  Congressman Richard Neal (D-Mass.) slammed the AHP rule, saying, “These garbage association health plans provide inadequate coverage, threatening the health and economic security of America’s families. As people buy into these shoddy plans, insurance costs rise across the board for everyone else.”

Bruce Auerbach, M.D., the president and CEO of Sturdy Memorial Hospital in Attleboro since 2014, resigned his post last Tuesday. In a letter to his Sturdy colleagues, Auerbach wrote, "There may come a time in our lives when personal issues and the health matters of family members, with which one must deal, impedes one’s ability to devote the time and  attention to the activities and professional responsibilities associated with high pressure jobs with significant time commitments." Auerbach served Sturdy Memorial's patients and communities for nearly 31 years, an experience he called "personally, unbelievably enriching." Sturdy's CFO and Treasurer Joseph Casey will serve as interim president and CEO until a permanent leader is found. Auerbach was a member of MHA’s Board of Trustees, and in that role and in other volunteer posts at MHA he assisted the association greatly, on a wide range of issues, through his deep knowledge of medicine and hospital operations. The many staff members at MHA who admire Bruce and befriended him through his no-nonsense but warm demeanor wish him the best.