Prior Authorizations, Rx Bill, and more ...

MassHealth Seeks to Expand Prior Authorizations

A new MassHealth policy that would require prior authorizations for more than 350 medical and diagnostic services is on hold for now as the state gathers feedback from those affected by the new rules. The procedures that are being considered include obstetric and non-obstetric ultrasounds, advanced imaging, radiation therapy, polysomnography, cardiology, and joint arthroscopy. 
Hospitals have many questions with the proposal and are concerned with the inclusion of ultrasounds, and especially obstetrical ultrasounds, in the list of procedures requiring prior authorization. MHA and others are now working with MassHealth to better understand the proposed policy and to incorporate provider feedback in any final version. A separate process is also underway to inform an additional proposed MassHealth prior authorization requirement for more than 200 specific drugs administered in hospital outpatient departments.
“We’re pleased that MassHealth is now engaging with providers and is considering our concerns and questions. New prior authorization requirements will undoubtedly increase administrative expenses and burdens of providers, and there are patient access concerns as well. In an environment where hospitals and providers are being held accountable for utilization, including through the MassHealth Accountable Care Organization program, the cost and value of these additional administrative processes should be considered carefully,” said MHA’s Senior Director of State Government Finance and Policy Dan McHale. 
Administrative costs have been a topic of discussion at the recent Health Policy Commission cost trend hearings. In its 2018 health cost trends report, the HPC stated that “the commonwealth should take action to identify and address areas of administrative complexity that add costs to the healthcare system without improving the value or accessibility of care.

Senate Rx Bill Gives HPC Even More Authority

This week the state senate is expected to begin deliberations on pharmaceutical cost control legislation. An Act Relative to Pharmaceutical Access, Cost and Transparency (PACT Act) would, among other things, expand state regulatory authority over drug prices, set limits on insulin costs, and include pharmaceutical manufacturing companies and pharmacy benefit managers in the Health Policy Commission’s (HPC’s) annual Health Care Cost Trends hearing process.
Specifically, the bill directs the HPC to establish a process for identifying drug price changes “that pose a public health threat” to residents and the state, and allows the HPC to “recommend pricing measures.” The bill also limits out-of-pocket insulin spending for residents by eliminating deductibles and coinsurance and capping co-pays at $25 per month. It also requires the Center for Health Information and Analysis (CHIA) to collect more data on drug prices than it currently does “to provide policymakers and consumers with an objective data source to understand drug cost drivers.”
By including pharmaceutical interests in the HPC’s cost trends hearings, those interests will be required to testify under oath and supply documentation about drug costs. The bill also requires HPC to create an “academic detailing program” to educate prescribers and other medical professionals on best practices to improve patient outcomes and reduce costs through better prescribing practices.
The expansion of the HPC’s regulatory authority and workload comes at a time when hospitals and insurers must fund the entirety of the HPC’s growing budget through annual assessments. The legislation that created the HPC allows, but doesn’t require, the state to pay up to a third of the HPC’s operating budget – but Massachusetts does not contribute to the funding. Hospitals that are self-insured not only pay their share of the hospital assessment but also are subject to the insurer surcharge as well. Under the Senate’s pharmaceutical cost bill, pharmaceutical and biopharmaceutical manufacturing companies, and pharmacy benefit managers will be required to pay an amount of the estimated expenses for the related new work of the HPC and CHIA, but are not included in the annual assessment to fund the agencies’ core work.

PSOs Can Help Prevent Future Patient Safety Events

About 59% of U.S. hospitals participate in a patient safety organization (PSO) program, according to an analysis from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG).
PSOs were created through the Patient Safety and Quality Improvement Act of 2005, and are used to collect, aggregate, and analyze patient safety information submitted by providers. All aspects of participation in a PSO program are voluntary.
Members of PSOs can collaborate freely in a privileged and confidential environment to discuss patient safety and quality issues. Such “safe table” meetings look at case scenarios such as suicide, opioids, behavioral health, medical errors, falls, shootings, etc. PSOs collect data and analysis of errors and near misses and, since they receive data from multiple sources, a PSO can identify event clusters earlier than individual members could.
The OIG found that nearly all hospitals with a PSO find it valuable. Among hospitals that work with a PSO, 80% find that the PSO's feedback and analysis on patient safety events have helped prevent future patient safety events. However, hospitals that do not participate in a PSO felt that PSOs are not distinct from other patient safety efforts. The OIG recommended that the Agency for Healthcare Research and Quality, which oversees the PSO program, undertake a strategy to communicate PSOs’ benefits.
In Massachusetts, MHA has selected the ECRI Institute as a patient safety organization available to MHA members, although some member hospitals are affiliated with other PSOs. Any hospital interested in learning more about ECRI or PSOs in general may contact Vice President of Clinical Integration Steven Defossez, M.D., at sdefossez@mhalink.org.

Veterans Face Special Health Challenges

As the nation honors the men and women who have served in the armed forces, it’s appropriate to recognize the special health challenges many veterans face.
According to the Veterans Administration, military personnel who have been on missions that exposed them to horrible and life-threatening experiences may now experience PTSD, or post-traumatic stress disorder.
The VA estimates that between 11-20% of veterans who served in Operations Iraqi Freedom and Enduring Freedom have PTSD in a given year. About 12% of Gulf War veterans have PTSD, and about 15% of Vietnam veterans were diagnosed with PTSD at the time of the most recent study in the late 1980s. But it is estimated that about 30% of Vietnam veterans have had PTSD in their lifetime.
Another cause of PTSD in the military can be military sexual trauma, according to the VA. This is any sexual harassment or sexual assault that occurs while a male or female is in the military, during peacetime, training, or war.
About 23% of women reported sexual assault when in the military, and 55% experienced sexual harassment. Thirty-eight percent of men in the military experienced sexual harassment.
The VA notes that there are many more male veterans than there are female veterans, so even though military sexual trauma is more common in women veterans, more than half of all veterans with military sexual trauma are men.
Also according to the VA’s latest available data (2017), approximately 17 veterans per day commit suicide. That shocking number is for veterans defined as “a person who had been activated for federal military service and was not currently serving at the time of death.”
Last week, in recognition of all of the challenges facing returning veterans, the Massachusetts House of Representatives passed a bill establishing a training program for college and university counselors who work with students who are veterans. The training, which would be developed by the University of Massachusetts Medical School, aims to ensure higher education institutions have resources available for students struggling with post-traumatic stress disorder, substance use, depression, or other issues stemming from military service.

DPH Issues a Reminder: Report Vaping Illnesses

DPH’s Bureau of Infectious Disease and Laboratory Sciences sent out a Clinical Advisory last Tuesday reminding providers that mandatory reporting of possible cases of unexplained e-cigarette or vaping-associated lung injury remains in effect. 
As of the end of October, there have been more than 60 confirmed or possible cases and three deaths in Massachusetts. DPH is also attempting to obtain clinical specimens from case patients for review by the federal Centers for Disease Control and Prevention, as well as vaping materials from case patients for Food and Drug Administration review.
See full details in the Clinical Advisory here.

NQF Offers Broad Suggestions on Star Ratings

The National Quality Forum (NQF) weighed in, to a limited extent, on the five-star hospital rating system that has been derided by many in the healthcare field as being an overly simplified and inaccurate way to communicate hospital quality.
NQF held a star rating summit in August to generate feedback on how to improve the system. Last week, NQF released three recommendations: 1) be clear about the program intent and goals; 2) be transparent about what the star ratings do and do not convey; and 3) design data presentations to meet consumer priorities and other user needs. 
Beneath the broad recommendations were more substantial suggestions such as regrouping measures to reflect “clinically meaningful domains and service lines,” and balancing the summary rating with the ability to “drill down for more detailed information.”
NQF’s 20-page report is here.

2020 Joint Commission Update

Friday, January 17, 2020; 8:30 a.m. - 2:30 p.m.
Conference Center at Waltham Woods, Waltham, Mass.

Hospitals need to stay abreast of the evolving compliance issues and shifting priorities regarding Joint Commission accreditation. At this year’s conference, we will hear from Gail Weinberger, director for state relations at The Joint Commission, and an expert on its standards. She’ll provide an update on the challenging standards from 2019 and highlight some of the new ones for 2020. We will also feature a hot-topics session and conclude the program with a panel of representatives from recently surveyed hospitals with the goal of sharing tips and updates about current priorities. Click here to learn more.

John LoDico, Editor