Workforce Safety, MHA Raps DHS Rule, and more ...

MHA Safety Conference Lays Groundwork for Progress

An important Healthcare Safety Summit MHA held last week featured experts from throughout the state discussing not only strategies to prevent healthcare violence and conflict, but initiatives to promote wellness and resilience in a workforce that is beset by constant physical, emotional, and spiritual demands.  The summit provided ideas and tools that participants could take back and use at their hospitals.

After opening remarks by Kim Hollon, president & CEO of Signature Healthcare, Bonnie Michelman, director of police, security, and outside services at Massachusetts General Hospital gave an overview of current trends and types of healthcare violence and conflict.  A panel of security personnel and clinicians shared best practices to defuse and prevent harmful incidents that may often occur in an environment where patients and caregivers are under intense pressure, where patients may be suffering from substance use disorders or psychiatric issues, and where there is open access into and out of the hospital.

Some common themes that emerged during the workforce engagement panel involved ensuring that the front-line staff knows that hospital leadership has their backs. That is, when patients threaten or verbally abuse staff it should not be considered “business as usual.”  The instinct to provide non-emergency care as quickly as possible may have to be overridden by the need to have a patient calm down first. Caregivers need to be supported when making such decisions and need to know that their safety is as important as patient safety.

And there must be strong documentation of violent and aggressive-behavior incidents. Often, because such activity happens frequently in care environments, the incidents aren’t noted and there’s no baseline against which to measure improvements. Hospitals are using new tools like the Collective EDie system to track prior incidents and provide a security alert so a hospital’s ED and security staff is aware of possible risks prior to interacting with a patient. This system also provides information about how providers have worked with, or provided successful de-escalation techniques to, a specific patient.  An MHA workgroup is developing a workplace safety and violence prevention guidance document to serve as a framework for hospital efforts in this area.

MHA also has undertaken a Caring for the Caregiver initiative to advance recognition, wellness, and resilience programs for caregivers.  (See related peer support story below.)  A panel featuring experts in this field discussed the need to empower all members of a caregiving team – including, importantly, security personnel.  Michael J. Goldberg, M.D., scholar-in-residence at The Schwartz Center for Compassionate Healthcare, spoke of how hospital security should be considered consultants with an expertise in de-escalation, who can form relationships with troublesome, repeat patients and contribute to caregiving.  There was also focus on applying the fourth arm of the Quadruple Aim – “Care of the Provider” – through tools such as mindfulness trainings brought to where care providers to help nourish their physical and psychological wellbeing.

Steve Walsh, MHA president & CEO, said of the summit, “We know that for our hospital workforce to provide the best care to patients our caregivers need to feel safe, appreciated, and healthy. Our summit was just one step in an ongoing process to help the people who have entered the caring professions maintain the passion and meaning that is inherent in their work – and to do their work without fear of violence.”

Clinician and Staff Peer Support Program Seeks Pilot Sites

One key takeaway that emerged from last week’s safety summit, it is that caregivers need support after traumatic events and shouldn’t “go it alone.” The Betsy Lehman Center is seeking five pilot hospitals to participate in creating a peer support program to help clinicians and other staff deal with medical errors and other unexpected patient outcomes. (The Center will also be creating a statewide peer support network for patients and families.)

Medical errors and other unexpected patient outcomes are obviously traumatizing for patients and families, but clinicians and staff also may suffer emotional or physical distress, believing they have failed their patients as they second guess their own clinical competence. Some even decide to leave their positions or professions. Caregivers are often reluctant to reach out for help following an incident for fear of being stigmatized or of compromising collegial relationships.

The five pilot sites will receive guidance in establishing a hospital-based multi-disciplinary team to oversee program development and implementation, and onsite training of peer supporters, among other benefits. If your hospital is interested in being considered for one of the five pilot test sites, please contact – by end of day Friday, Dec. 14 – Linda Kenney at Linda.kenney@state.ma.us or (617) 701-8193.

MHA Opposes Changes to “Public Charge” Immigration Rules

In a strongly worded letter to the U.S. Department of Homeland Security (DHS) sent last Friday, MHA outlined its opposition to a proposed federal rule that MHA says will destabilize Massachusetts healthcare by, among other things, making it harder for immigrants to access medical care. MHA said the rule also would have the unintended consequence of inhibiting medical care for immigrants’ family members, many of whom may be children and U.S. citizens.

At issue is how the rule re-defines who could be determined a “public charge” of the government and therefore potentially ruled inadmissible for immigration into the U.S. A public charge is an individual who is likely to become “primarily dependent on the government for subsistence.” For the past 20 years, this has been limited to receipt of cash assistance and using long-term care at the government expense.

Now, under the proposed rule change, the federal government is proposing to use healthcare programs relating to certain Medicaid benefits and Medicare drug subsidies as part of the evaluation process.  Other benefits such as Supplemental Nutrition Assistance Program (SNAP) and housing programs are also proposed to be included in the “public charge” assessment.  The proposed rule would also evaluate whether an immigrant would likely to use these services at any time in the future, and include factors based on income, assets, age, and health.

“Massachusetts hospitals and healthcare providers are very concerned that the proposed rule will dissuade thousands of low-income Massachusetts residents from seeking health coverage,” MHA wrote in its letter. “An expansion of [the public charge] definition to include healthcare benefits such as Medicaid will likely mean many immigrants will withdraw or forgo applying for health coverage programs. Worse, many may also forgo even seeking medical care if they believe it will be a potential negative factor in their future immigration status.”

MHA added that aside from Medicaid, “The proposed inclusion of SNAP and federal housing support in the immigration status evaluation process will have a negative influence on people seeking these needed supports and will ultimately lead to unfavorable health consequences.”

While the new rule is aimed at those in the immigration pipeline, MHA said it could have a “chilling effect” on those not even affected by public charge rules. MHA wrote:  “We believe the rules will create a fear that their own immigration status or that of a family member will be affected by their participation in federal or state programs, which will cause these immigrants to forgo or withdraw from health coverage programs.  Immigration statuses and rules are complex, making it difficult for individuals to understand whether these rules would apply to them.  Also, a ‘family’ can include members directly affected by the policy as well as those that are not, including U.S. born children.  Many families will see this change as a choice between keeping their families whole or keeping them healthy.”

In addition to MHA’s comments, numerous hospitals, healthcare providers, and others concerned with healthcare access across Massachusetts have submitted comment letters. In an advisory to its members informing them of the proposed rule and encouraging comments to DHS, MHA also included resource documents hospitals can use to direct individuals concerned about their immigration status to immigration experts in their communities.

New Rx Rules: Concerns About Unintended Consequences

The Board of Registration in Pharmacy’s much anticipated regulations on how a pharmacy can conduct sterile compounding pose potential unintended consequences that could increase costs and disrupt patient care, according to comments from MHA and Massachusetts Society of Health-System Pharmacists (MSHP).

The board approved the regulations last Thursday and much of the new rule reflects input offered by MHA and MSHP members.  But of great concern, according to the two associations, the proposed Massachusetts rules go far beyond the national evidence-based, expert consensus driven standards within Untied States Pharmacopeia Chapter 797.

Four areas relating to the pharmacy’s physical structure, environmental monitoring, personnel expansion and training, and increased reporting could result in “exorbitant investments, for some hospitals in the millions of dollars, just to meet compliance in facility structure and the hiring of additional staff to comply with monitoring and reporting requirements that will not improve sterile compounding practices,” MHA and MSHP wrote.  The two groups asked the board to amend the regulation further to make it conform closer to the existing national standard in USP 797.

Almost All Health Insurers in Mass. Were Profitable in 2018

MHA’s Semi-Annual Year-End Health Plan Performance Report covering the period from January 2014 to June 2018 has been released and shows that 8 of 10 health insurance companies operating in Massachusetts were break-even or profitable in 2018. Both of the plans with negative profit margins were both greater than -1%. However, there was a net decrease of 90,000 enrollees in all plans.  MHA’s Semi-Annual Year-End Health Plan Performance Report presents an analysis of the financial position of health plans in Massachusetts by looking at a variety of measures, including: plan membership, premium rates, medical and administrative expense trends, profitability, liquidity, and solvency. It gives providers information about health plan market share, and it presents trends in premium rates to employer groups. The report is available to MHA members only on the My MHA page of mhalink.org under “Resources.”

Employer Group to Focus on ED Utilization

The Massachusetts Employer Health Coalition (MEHC) – a new group consisting of employer associations working with healthcare “strategic partners” – holds its kickoff breakfast meeting tomorrow at The University of Massachusetts Club in Boston.

MEHC’s goal is to engage employers, hospitals, insurers, government, unions, and other stakeholders to reduce avoidable emergency department use, which has been identified as a contributor to rising healthcare costs.  The Health Policy Commission has estimated that avoidable ED visits cost $300-350 million annually for commercially insured members alone.  MHA is a strategic partner in the MEHC effort.
Among MEHC’s goals, in addition to engaging workers on the issue and improving data measurement, is to “align financial incentives across hospitals, health care providers, health plans, employers, and employees to reward and encourage the timely delivery of care in the most appropriate setting.”

Tomorrow’s meeting will feature new HPC data, and a presentation from the Midwest Health Initiative and the St. Louis Area Business Health Coalition (BHC), discussing a multi-stakeholder effort to measure, report on, and reduce potentially avoidable ED use in St. Louis. View more about MEHC here.

AHA Sues to Stop Off-Campus Provision of Final Medicare Rule

The American Hospital Association (AHA), the Association of American Medical Colleges, and a group of affected hospitals are suing the federal government over a new rule that changes how certain off-campus hospital departments are reimbursed for the care they provide patients.

CMS’s final outpatient prospective payment system rule (OPPS) issued last month includes a plan to reduce Medicare payments for certain services provided at off-campus hospital provider-based departments (PBDs). These PBDs are defined as practice locations that are not located in the immediate proximity of the main hospital but are nonetheless closely integrated with and controlled by the hospital. Examples are stand-alone oncology clinics, urgent care clinics, or medical offices offering specialized care.  Oftentimes these services are located off campus to bring services to a convenient location for patients in a given community.

The new federal rule would essentially treat the off campus provider-based departments similar to a physician office – and pay them the same, lower rate.

In its lawsuit, the AHA says that the off-campus PDBs often have higher costs, writing: “There are many reasons for this: The patient population that visits off-campus PBDs tends to be sicker and poorer than the patient population that visits independent physician offices … In addition, off-campus PBDs are often intended to serve more functions than standalone physician offices. For example, an off-campus PBD may be an emergency department operating on nights and weekends with a team of specialist doctors and nurses on staff. In addition, CMS requires off-campus PBDs to satisfy the Medicare Conditions of Participation applicable to their main hospital, which are more demanding than the requirements imposed on physician offices or clinics.”

The lawsuit says CMS exceeded its authority and overrode Congressional intent by issuing the final OPPS rule relating to off-campus payments, and asks the U.S. District Court for the District of Columbia to stop the rule from being enforced.

52nd Annual Mid-Winter Leadership Forum

Thursday, February 7, 2019; 8:30 a.m. – 2:30 p.m.
Sheraton Hotel, Framingham, Mass.

This is the MHA event of the winter and the Mid-Winter Leadership Forum planned for February promises to be a good one. The confirmed keynote speaker is David Gergen, director of the Center for Public Leadership at Harvard Kennedy School, and senior political analyst for CNN.  Gergen has served as a White House adviser to four U.S. presidents of both parties: Nixon, Ford, Reagan, and Clinton. He wrote about those experiences in his New York Times best-seller, Eyewitness to Power: The Essence of Leadership, Nixon to Clinton (Simon & Schuster, 2001). Additional confirmed sessions include: Elisabeth Rosenthal, M.D., editor-in-chief of Kaiser Health News and the author of An American Sickness, which takes a harsh look at the U.S. healthcare system; and Francis X. Campion, M.D., senior clinical informaticist for IBM Watson Health, and an internist at Atrius Health, who will discuss “Artificial Intelligence for High Value Healthcare.” Don’t miss this year’s Mid-Winter Forum.  More details to come, but visit here to register now.

John LoDico, Editor