The Benchmark, MDs & Readmissions, and more ...

Benchmark Set; Data Lags Put 2015-16 Costs in Spotlight

The Health Policy Commission (HPC) last week voted to set the statewide healthcare cost growth benchmark for calendar year 2020 at 3.1% – which was not unexpected.
By statute, between 2018 and 2023, the benchmark is calculated by subtracting 0.5% from potential gross state product (currently 3.6%), to arrive at 3.1%. The HPC has the ability to raise the benchmark after going through its hearing process with the Legislature. After 2023, the HPC can modify the benchmark to any amount, subject to legislative approval.
No one expected last week that the HPC would raise the threshold from 3.1% as the total healthcare expenditures per capita in Massachusetts grew just 1.6% from 2016 to 2017, which is well below both the state’s healthcare cost growth benchmark and national growth rates. But HPC Chairman Stuart Altman indicated that since healthcare cost growth in the state and nationally has slowed, it may be time to free the HPC from its statutory limits and allow it to drive down the benchmark.
“It may be time to consider whether additional flexibility is warranted for the HPC to set the benchmark lower than 3.1%,” Altman said.
In its previous comments to the HPC, MHA, along with the majority of other healthcare entities commenting, concurred that the benchmark should be set at the lowest allowable level – or 3.1%. At the same time, MHA noted a number of challenges to the healthcare cost equation that remain largely beyond the control of hospitals and providers, ranging from the rising cost of pharmaceuticals and labor to the effects of demographics and an aging populace. MHA also cautioned that the cost growth benchmark should be used for its intended purpose (to rein in costs) and not for other reasons (such as being a sort of quasi price cap by insurance companies in their negotiations with hospitals). The HPC last week noted this provider concern.
The other noteworthy news to emerge last week from the HPC is that the state’s Center for Health Information and Analysis (CHIA) has referred 35 providers and six payers to the HPC for potential Performance Improvement Plans (PIPs). By statute, providers subject to a potential PIP are not publicly identified. When a provider or payer doesn’t meet the benchmark for all or part of its business, the HPC has the authority to investigate it and, if warranted, request a performance improvement plan to explain how the provider/payer is going to come back into cost-growth compliance. The HPC noted at the meeting that it has never required a performance improvement plan of any entity under this process.
Of the 35 providers, 27 were referred to the HPC for growth in one contract or book of business. So, for instance, if one hospital is meeting the benchmark in all of its dozens of contracts with insurers, but pushes past the benchmark in, say, a Preferred HMO contract with one insurer, it will be referred to the HPC. The contracts and books of business at issue last week were ones that existed in 2015-2016. CHIA has a three-year lag, which the HPC noted “may not reflect the entity’s current performance.”

How Can Physician Practices Help Reduce Hospital Readmissions?

Among the many studies on hospital readmissions, one point that continually emerges and is generally accepted is that the entire healthcare system – from physicians’ offices to hospitals, post-acute providers, home care agencies, and even patients and family caregivers – must work together to reduce a patient’s need to revisit a hospital within 30 days of discharge.
In the current healthcare system, although there is much collaboration to ensure patients progress through the system and receive timely follow-up care, any break in that chain most likely results in a patient returning to the hospital and definitively results in the hospital alone suffering a financial penalty. 
Now, the Agency for Healthcare Research and Quality (AHRQ) has released a report that identifies primary care-based strategies for reducing hospital readmissions.
“Many efforts to reduce readmissions have focused on the hospital setting and staff using evidence-based programs,” AHRQ wrote. “…The evidence-base for the primary care setting on how to reduce readmissions and improve patient safety is comparatively lacking. This gap in the literature is becoming more pronounced as primary care is increasingly called to serve as the key integrator across the health care system as part of payment and delivery system reforms.”
The AHRQ report – essentially an environmental scan on what is currently known about reducing readmissions from the primary care perspective – found that the characteristics of various practices makes it difficult to pinpoint specific things they can do to support effective care transitions. “Primary care may play a small to large role in care transition interventions, and the complexity of these interventions can vary greatly depending on circumstances in their health system environment and relations with other health system members,” AHRQ wrote.
Nonetheless, a key takeaway AHRQ found is that multi-component interventions that addressed multiple challenges of patients and providers tended to be more effective than individual interventions. Also, care transition programs in the context of more general primary care transformation efforts, such as the patient-centered medical home, tended to be more effective.
In Massachusetts, hospitals have been engaged in a variety of efforts to reduce readmissions, most recently in the ongoing Hospital Improvement Innovation Networks (HIIN). MHA is coordinating a 10-hospital HIIN in Massachusetts throughout 2019, the main goal of which is to reduce all-cause inpatient harm by 20% and readmissions by 12%. Other Massachusetts hospitals are participating in a HIIN coordinated by AHA.

A Reasoned Argument for a Sugary-Drink Tax

This legislative session, one bill that MHA and the hospital community is solidly behind would raise the tax on sugary drinks. Specifically, H2529/S1709, An Act to Promote Healthy Alternatives to Sugary Drinks, sponsored by Rep. Kay Khan (D-Newton) and Sen. Jason Lewis (D-Winchester), 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 healthcare community, alarmed by the rapidly increasing rates of childhood diabetes and obesity, and armed with numerous studies proving the link between those health problems and sugary drinks, feels support of the legislation is a “no-brainer.”
Now, others are joining the fight. Last week, The Berkshire Eagle editorial board weighed in, saying, “The scientific and medical evidence is in, and excess sugar in the American diet has been shown to be a cause of heart disease, diabetes and obesity in an ever-younger cohort of the populace.”
The editors added, “Those who insist that a sugary drink tax hurts those who can least afford it may wish to consider the state cigarette tax, which arguably does the same. Moreover, like cigarettes, sugary drinks are not a life necessity … A tax on harmful consumables, rather than a ban, still allows individuals to make their own choices while making strides toward achieving a collective beneficial effect.”

State Leaders Weigh in with the Feds on Opioid Issues

The Governor, Lt. Gov., Speaker, and Senate President

 Opioid prescriptions in the state have decreased by 35% since 2015 and the tragic death toll from opioid overdoses is trending down in Massachusetts. But despite the progress, the healthcare community and state political leaders are not letting up on the issue.
On April 2, Governor Charlie Baker, Lt. Gov. Karyn Polito, House Speaker Robert DeLeo, and Senate President Karen Spilka teamed up to draft a succinct letter to FDA Commissioner Scott Gottlieb, M.D., that contained two asks.
First, the elected leaders wrote, “[T]he FDA should revise the labeling for opioids to return to evidence-based language about the safety and efficacy of these drugs. Despite significant evidence that opioids are only effective for short-term treatment of acute pain, the FDA in 2001 changed the labeling to indicate that these addictive drugs could be prescribed for extended periods of time to treat chronic pain. Those suffering from chronic pain can and should continue to have access to pharmaceutical treatments that can help alleviate their suffering, but it is important that patients and their doctors are informed about the science when making those decisions. The FDA should not wait years for drug manufacturers to conduct studies on the effectiveness of opioids in treating chronic pain; the agency should rely on the significant body of existing research and immediately return to the labeling in place prior to 2001.”
Secondly, the Massachusetts leaders asked the FDA to use its new authority under the recently enacted SUPPORT Act to require “unit of dose packaging” for opioids. That is, dispensing prescriptions for opioids in per-dose packaging (for example, pushing a pill through a foil wrap) as opposed to giving a patient all of the pills in a single container.
“States are on the front lines of the opioid epidemic, but we cannot do this alone,” the Bay State leaders wrote.

The Attorney General

Massachusetts Attorney General Maura Healey joined 38 other AGs in signing a letter to the U.S. Department of Health and Human Services (HHS) criticizing the department for issuing draft opioid prescribing guidelines that vary from components of the 2016 guidelines that the Centers for Disease Control and Prevention (CDC) issued.
In general, the CDC guidelines call on prescribers to follow evidence-based recommendations for dispensing opioids, while HHS’s proposed guidelines leave dispensing decisions solely to the provider.
The AGs’ sharply worded letter say it is “incomprehensible that officials would consider moving away from” the CDC’s 2016 guidance.
The 39 AGs say they are concerned that the new rules downplay the risk of high-dose opioids, fail to acknowledge that “longer duration prescriptions increase patients’ risk for misuse,” and “provides no justification for moving away from the CDC recommendation that clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.”
“Since the CDC Guideline was issued, the evidence has continued to mount that opioids achieve limited pain relief for chronic non-cancer pain and are often no better than other options for treating acute pain,” the letter states. “… As a matter of public safety, there is simply no justification to move away from the CDC Guideline to encourage more liberal use of an ineffective treatment that causes nearly 50,000 deaths annually.”
MHA, working with experts from its member hospitals and allies across other healthcare entities, has in recent years created evidence-based guidance for healthcare professionals to follow in an effort to curb substance use disorder. MHA has assisted hospitals in creating programs for Medication for Addiction Treatment within the Emergency Department, Opioid Management within a Hospital Setting, Emergency Department Opioid Management, and for Preventing Opioid Misuse in Hospitals. Information about these initiatives is located on PatientCareLink.

Fourth Annual Summit of Mass. Coalition for Serious Illness Care

The Massachusetts Coalition for Serious Illness Care, of which MHA is a member, holds its fourth annual summit on Thursday, May 16, from 9:30 a.m. to 2 p.m. at the John F. Kennedy Presidential Library and Museum in Boston.
At this year's summit, the coalition will share the results of its messaging research project, including tested language for engaging the broader public, as well as targeted segments of the population, in conversations about what really matters to their life and health.
Presenters at the summit include Maureen Bisognano, president emerita and senior fellow at the Institute for Healthcare Improvement; Andrew Dreyfus, president and CEO, Blue Cross Blue Shield of MA; Atul Gawande, M.D., CEO of Haven (the Amazon, Berkshire Hathaway, and JPMorgan healthcare venture); and Ellen Goodman, co-founder and director of The Conversation Project. More details to follow, but you can register now by clicking here.

MHA's 83rd Annual Meeting

Wednesday, June 12 - Friday, June 14
Chatham Bars Inn, Chatham, Mass. 

We’ve added two new speakers to our lineup at this year’s MHA Annual Meeting: Congressman Richard Neal, the chair of the U.S. House’s Ways & Means Committee and a healthcare champion throughout his 30 years in Congress. Also speaking is Luba Greenwood, of Google Verily’s Strategic Business Development and Corporate Ventures. Greenwood brings to Google pharmaceutical, biotechnology, and digital health industry experience and expertise in building and investing in innovative technology companies and providing strategic counsel to global corporations. MHA’s annual meeting also will feature Steve Pemberton, chief diversity officer, Walgreens Boots Alliance; and Kim Lear, speaker, writer, strategist, researcher, and “true generational expert.” A series of engaging panels and activities make the annual meeting the one can’t-miss event of the year. Get more details, registration and lodging information, and more by visiting here.

John LoDico, Editor