Attacking & Supporting the ACA, Plus Star Ratings, and more....

President, Declaring He Now Understands Healthcare, Moves to Gut ACA

The Trump administration last week asked a U.S. Appeals Court to strike down the entire Affordable Care Act (ACA).
The decision brought immediate condemnation from hospital and healthcare interests.
MHA President & CEO Steve Walsh said, “Improving healthcare delivery is a shared goal and an evolving process. But this effort to dismantle the ACA rather than make thoughtful changes to our existing system of care is an extraordinarily shortsighted and harmful move that will create long-lasting repercussions for patient coverage and access.”
American Hospital Association (AHA) President Rick Pollack said, “Millions of Americans would lose the coverage they have relied on for years. We have made too much progress in coverage and access to care for patients to go backwards. If courts were to adopt the [U.S. Department of Justice] position, Medicaid expansion would be reversed and protections for people with chronic and pre-existing conditions would cease to exist.”
The Fifth Circuit Court of Appeals is reviewing last year’s decision from a U.S. District Court judge in Texas that struck down the ACA. Twenty-one Democratic Attorneys General, including the commonwealth’s AG Maura Healey, are appealing that ruling. The Democratic-controlled U.S. House of Representatives also filed a brief in support of the ACA. AHA plans to file an amicus brief today, urging the Court of Appeals to reject the lower court’s decision. Also a group of 26 state hospital associations, including MHA, are filing an amicus brief urging the Court of Appeals to reverse the district court’s order.
Last week’s filing by the Trump Administration’s Justice Department asks the Appeals Court to let the lower court ruling that gutted the ACA stand. The DOJ position surprised many because last year the Justice Department argued against the pre-existing portion of the ACA but endorsed retaining the bulk of the law.
President Trump last Wednesday said of the DOJ filing, “I mean it 100 percent, I understand healthcare now, especially very well. A lot of people don't understand it – we are going to be, the Republicans, the party of great healthcare.”
In 2017, Congress struck down one element of the ACA that imposed a tax penalty on those who chose to maintain healthcare coverage. Those who brought suit against the ACA in Texas argued, essentially, that Congress’ no-tax action turned the ACA’s remaining minimal coverage provision into a stand-alone and, ultimately, unconstitutional command to buy insurance. The 21 AGs rejected that argument in their brief last week, arguing, among other points, that the plaintiffs don’t have standing “because they suffer no legal harm from the existence of a provision that offers them a lawful choice between buying insurance or doing nothing.”
The DOJ announcement is not expected to affect the timeline of the appeals process, which will continue with arguments taking place sometime in mid-to-late 2019. A decision is expected in either late 2019 or early 2020.

Don’t Destroy the ACA; Improve It

The Trump Administration’s move last week to eliminate the Affordable Care Act (ACA) was countered by House Democrats who introduced a series of bills to do just the opposite – strengthen the ACA and expand its reach. While countering ACA opponents, the Democratic package that House Speaker Nancy Pelosi and committee chairs put forward is also an alternative to the various “Medicare for All” bills that Democrats have introduced.
The ACA legislative package would, among other things, increase tax credits and cost-sharing to allow more people to buy insurance; that is, raise the income level above which people are ineligible for tax credits to purchase insurance. The bills would also restore the funding that President Trump cut from programs to inform people about their insurance options and subsidies available to them. 
The Democratic bills would force the low-cost, limited-benefit plans that the Trump Administration allowed last year to conform to the ACA’s minimal coverage requirements. That means they would now have to cover prescription drugs, maternity care, drug abuse treatment, and pre-existing conditions.

Many of the elements of the new bills are carry-over ideas from a previous bill drafted by Reps. Richard Neal (D-Mass.), Frank Pallone (D-N.J.), and Bobby Scott (D-Va.).
There are approximately 2.5 million Massachusetts residents with pre-existing health conditions who benefit from the ACA; more than 300,000 Massachusetts residents have received coverage through the ACA’s Medicaid expansion; more than 283,000 individuals purchased insurance through the state’s health exchange as of February 2019, including more than 224,000 with the support of ACA advanced premium tax credits that the current proposed bills would expand.

MHA Urges CMS to Fix Flaws in Star Ratings

The Centers for Medicare and Medicaid Services (CMS) since 2016 has used a one-to-five star system to rate hospitals to give a simplified view of hospital quality to consumers. But, for a variety of reasons, the star system is essentially meaningless, gives an inaccurate view of quality, can’t be used by hospitals to improve quality, and should just be scrapped, according to a letter MHA sent to CMS last Friday.
“Unless and until the ratings methodology is improved, it will be difficult for hospitals and the public to have confidence that star ratings portray hospital performance accurately and may, in fact, mislead consumers about the best or most appropriate place to seek care,” MHA wrote.
If a consumer wants to find out if a hospital is renowned for, say, cancer care or heart surgeries, that consumer using the star system isn’t presented with any specific information about those care disciplines; instead she is given a single representative star score assessing a facility’s “quality.” Hospitals, since the inception of the star ratings, have complained that they have virtually no way to predict how their performance on the underlying measures will translate into a star rating. This means the ratings are of little value to improvement efforts.
The star ratings continue to include measures with known methodological flaws (such as the “patient safety indicator (PSI) composite measure,” which is regularly criticized as lacking validity) and they are known to put excessive weight on some measures (hip/knee complications) while not placing enough emphasis on really significant measures, such as those tracking infections.
And the ratings penalize the hospitals that treat the most complex cases or the most disadvantaged communities. “The ratings must account adequately for differences in the clinical and social risk factors across the patients and communities that hospitals serve,” MHA wrote. “The AHA has noted repeatedly that the current approach to ratings disadvantages hospitals caring for poorer communities, as well as those like academic medical centers that tend to care for higher complexity patients and critically ill patients transferred from other sites.”
In its letter, MHA delves deeply into some technical points that could improve how ratings are arrived at, but the overall recommendation to CMS is to just get rid of the simplistic notion of rating a hospital like a consumer magazine rates a dishwasher or an automobile.
“The very notion of trying to quantify overall hospital quality into a single composite score is flawed in its design of simplifying very complex data into a ‘one size fits all’ rating that may not be truly representative of all cases,” MHA wrote. “The data and performance rates for the inpatient and outpatient quality reporting measures should speak for themselves as individual measures.”

Mount Auburn’s Clough Presented Top AHA Award

Congratulations to Jeanette Clough, the president & CEO of Mount Auburn Hospital and a former MHA Board Chair, who will receive the American Hospital Association 2019 Board of Trustees Award in recognition of her “substantial and noteworthy contributions” to the work of AHA. AHA will present the award at its annual membership meeting April 8 in Washington, D.C. Also receiving this year’s award is Bruce Bailey, president and CEO of Tidelands Health in Georgetown, S.C.
Clough is the chair of AHA's Health Forum and has helped guide that organization as a board member since 2012. In addition, she currently serves on the AHA Center for Health Innovation Leadership Council, and is a past member of the AHA Board of Trustees, chair of Regional Policy Board 1, and chair of the Committee on Performance Improvement. AHA President and CEO Rick Pollack said Clough’s “keen insights and in-depth knowledge” have made her “an invaluable leader in our field.”
On May 15, Clough will be the keynote speaker at the Cambridge Chamber of Commerce’s Inspire Awards, which celebrate the achievements of women leaders. That lunchtime event is at the Royal Sonesta Hotel. Visit www.cambridgechamber.org for more details.

Groups Urge Sugary Drink Tax to Protect Kids; Mass. Has One on Tap

Last week, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) encouraged the passage of legislation designed to reduce children’s consumption of sugary drinks.
The AAP and AHA recommended that state and federal legislators consider raising the price of sugary drinks, such as through an excise tax; that the government should support efforts to decrease sugary drink marketing to children and teens; and that federal nutrition assistance programs should ensure access to healthy food and beverages and discourage consumption of sugary drinks. The groups also urged that consumers have “ready access to credible nutrition information, including on nutrition labels, restaurant menus, and advertisements;” and that “hospitals should serve as a model and establish policies to limit or discourage purchase of sugary drinks.”
The two groups said children and teens now consume 17% of their calories from added sugars—nearly half of which come from drinks alone. Dietary guidelines recommend fewer than 10% of calories from added sugars. Excess sugars lead to tooth decay, diabetes, obesity, and heart disease. Teens who get more than 10% of their daily calories from added sugars are more likely to have abnormal cholesterol levels, including higher “bad” LDL cholesterol, higher triglycerides, and lower heart-protective HDL cholesterol.
In Massachusetts this legislative session, MHA is strongly supporting H2529/S1709, An Act to Promote Healthy Alternatives to Sugary Drinks, sponsored by Rep. Kay Khan (D-Newton) and Sen. Jason Lewis (D-Winchester). The bill would implement a tiered-tax on non-alcoholic sugar-sweetened beverages based upon the drink’s sugar content. Proceeds from the tax would help fund a variety of community health initiatives. 
The bill recommends three tiers of taxation: drinks with little or no added sugars (7.5 grams of sugar per 12 ounces) will not be taxed at all; drinks with moderate amounts (7.5 to 30 grams) will be subject to a 1-cent-per-ounce tax; and drinks with 30-plus grams per 12 ounces would face a 2-cent-per-ounce assessment. Beverages consisting of 100% natural fruit or vegetable juice with no added sugars would be exempt from the tax. A 12 ounce can of Coca Cola has about 39 grams or 9.3 teaspoons of sugar.

Hepatitis A is Spreading Nationwide – and in Massachusetts

The Centers for Disease Control and Prevention (CDC) is reporting a nationwide outbreak of hepatitis A, primarily among people who use illicit drugs (injection and non-injection) and those who are homeless. More than 15,000 cases, 8,500 hospitalizations, and 140 deaths as a result of hepatitis A virus (HAV) infection have been reported since 2016. 
“CDC recommends that public health departments, healthcare providers, and other partners serving affected populations launch a rapid and effective public health response,” including offering vaccinations to targeted populations. For healthcare providers specifically, CDC recommends screening patients for risk factors (drug use, homelessness, incarceration, sex between men, and chronic liver disease); administering the hepatitis A vaccine to at-risk patients, especially those whose only point of contact with the health system is through an emergency department; reporting immunizations and diagnoses with the state; and considering hepatitis A as a diagnosis in anyone with jaundice or clinically compatible symptoms.
The Massachusetts Department of Public Health along with local boards of health is tracking the outbreak of hepatitis A in Massachusetts. Information about the outbreak in the commonwealth, its epidemiology, as well as educational materials is all available here.

MHA’s Annual HR/Labor Forum
Caring for Caregivers: Making the Case for Clinician Wellbeing & Resilience

Friday, May 3, 9 a.m. - 3 p.m.
MHA Conference Center, Burlington, Mass.

Healthcare’s disruptive forces are putting unprecedented stress on caregivers and the broader healthcare workforce. From onerous regulatory requirements to difficult workplace and societal issues, challenges arise every day, adding to burnout and lowered morale. Using emerging research and creative ideas, some healthcare organizations are tackling clinician wellbeing as a top-level priority. Development of resilience training and the creation of new executive-level Chief Wellness Officers are examples. Some healthcare organizations are even promoting the concept of "joy at work." Join us at this year’s forum, where we’ll look at the importance of clinician wellbeing, and how healthcare organizations can be proactive and innovative to create a better environment for both workers and their patients. Click here to see the impressive lineup of speakers, as well as registration info.

John LoDico, Editor