Vaccine Mandates; Senate Spending Bill

Senate to Debate its Spending Bill This Week

The Massachusetts State Senate begins debate Wednesday on a bill that distributes $3.67 billion in state surplus funds and money Massachusetts received through the federal American Rescue Plan Act (ARPA). The Massachusetts House on October 29 passed its plan for expanding ARPA-surplus monies.
Among its many provisions, the Senate proposal would fund: premium pay bonuses for essential frontline workers, who worked during the height of the pandemic ($500 million); a mental and behavioral health reserve ($400 million, with $100 million of that going to a loan repayment assistance program and $240.4 million transferred to a behavioral health trust fund); and acute care hospitals serving communities that the pandemic disproportionately affected ($200 million).
MHA said it appreciates the Senate’s support for hospitals and the significant proposed investments towards behavioral health reform, and filed three amendments on this front. The first would extend eligibility for loan forgiveness programs to staff working in inpatient psychiatric units, in addition to those employed by freestanding psychiatric hospitals. The second would add an MHA seat to the advisory commission tasked with determining use of the $240.4 million in behavioral health trust fund dollars. Lastly, MHA sponsored an amendment to require that the advisory commission considers use of the monies for workforce scholarships, training, and retention programs; while loan repayment opportunities are a critical component of workforce development, the bill would be more impactful in rebuilding the worker pipeline if it also funded scholarship and training to help existing mental health workers rise up the career ladder. 
“Throughout the course of the pandemic, Massachusetts state government – unlike what we’ve seen in other parts of the country – has responded promptly and ably to address the needs of the commonwealth’s healthcare community in its fight against COVID-19,” said Emily Dulong, MHA’s VP of Government Advocacy & Public Policy. “We look forward in the coming days and weeks to working closely with the legislature to ensure health systems receive the appropriate relief that recognizes their tireless efforts over the past two years.”

Financially Harmed During FY20, Hospitals Provided Community Benefits

Massachusetts hospitals contributed $786 million to their communities during fiscal year 2020 even while financially stretched thin by the persistent pandemic, according to community benefits figures issued last week from Attorney General Maura Healey’s office.
“The COVID-19 crisis has placed enormous strain on our healthcare system, exposing and exacerbating existing health inequities,” Healey said. “In the face of these challenges, hospitals and HMOs found ways to not only sustain investments in their communities, but to expand them to address heightened needs during the pandemic.”
Forty-seven non-profit acute care hospitals reported a total of $746 million in community benefit expenditures in FY2020, and 10 investor-owned hospitals reported another $40 million in outreach to communities. The hospital-funded programs focused on the four statewide health priorities – chronic disease, housing stability and homelessness, mental health, and substance use disorders – as well as other programs that hospitals and their communities determined were priorities. About $354 million of the hospital expenditures went towards providing free or discounted care to patients. Health insurance companies also file community benefit reports; FY2020 showed the plans reporting about $163 million in community benefits, of which $113 million is attributed to their required contribution to the Health Safety Next. Hospitals contribute $165 million to the safety net and cover all shortfalls to that fund.
According to the AG’s Office, the 2020 reporting allowed hospitals to tag new community benefit programs related to the pandemic; 69 programs in 2020 include the new tag. The AG’s Office also allowed all hospitals and HMOs the option to update their Community Benefits Implementation Strategies (included in the Community Benefits reports) to account for new community needs and programs related to the pandemic. 
As has been true in prior years, many hospitals construct their community benefits programs to address health inequities and social determinants of health.

One Source of Hospital Funding Has Run Its Course

The Community Hospital Reinvestment Trust Fund (CHRTF) program that for five years provided about $45 million to hospitals to fund programs that benefit the uninsured, underinsured, and MassHealth populations is being phased out.
Last week, the Executive Office of Health and Human Services issued the last $10 million installment to 49 hospitals. CHRTF was created by law in 2016 and was funded by transfers to the fund from the Center for Health Information and Analysis (CHIA). Assessments on hospitals fund a majority of the CHIA budget and operations of the Health Policy Commission. Hospitals that received CHRTF funding have lower relative prices. The law that created CHRTF also put a sunset date on it of 2021.

All Healthcare Workers Must Be Vaccinated by January 4

Nearly all U.S. healthcare providers will have to ensure that all of their staff have received either the one-shot Johnson & Johnson COVID-19 vaccine, or the first of a two-dose vaccine, by December 5, and then make sure their staff is fully vaccinated by January 4, 2022, according to CMS rules released last Thursday.
The rule applies to nearly all types of providers that receive Medicaid or Medicare funding, but does exclude certain sites such as assisted living facilities, physicians’ offices, and group homes. CMS clearly states that the federal vaccination requirement pre-empts any state law that is contrary to the federal requirement.
The rule also applies to nearly all types of staff, including those who perform duties off-site, such as those conducting home infusion therapy. But those who provide full-time telework services are excluded. There are also exceptions for medical or religious reasons; if a worker meets one of these exceptions and remains unvaccinated, the facility must develop a process for mitigating transmission, which could involve reassigning the non-vaccinated staff to non-patient care settings. Providers are not required to, but may voluntarily institute testing alongside other infection prevention measures.
MHA and its Board of Trustees are on record endorsing mandatory vaccines for healthcare workers.
The Occupational Safety and Health Administration also issued an emergency temporary standard requiring all employees at private businesses with 100 or more workers to be vaccinated by January 4 or get tested for COVID-19 weekly.

Ensuring the No Surprises Act is Done Right

Many members of Congress have signed on to a letter that urges federal agencies to re-draft the rule that will be used to implement the “No Surprises Act” – the law that protects patients against surprise billing and attempts to resolve payment disagreements between providers and insurers.
The carefully drafted bill that passed with bipartisan support allows providers and payers unable to reach agreement on payment to pursue an independent resolution process (IDR). The alternative was to have the government set a benchmark rate for payment disputes – but Congress rejected that. 
However, in September, U.S. Health & Human Services, the Treasury Department, and Department of Labor released their interim final rule (IRF) that instructs the IDR entity brought in to resolve disputes to start with the presumption that the median in-network rate is the appropriate payment, creating a de facto benchmark rate. That’s contrary to what Congress intended, according to a letter singed by nearly 150 members of Congress, including Massachusetts Representatives Stephen Lynch and Jim McGovern. 
“The process laid out in the IFR does not reflect the way the law was written, does not reflect a policy that could have passed Congress, and does not create a balanced process to settle payment disputes,” the letter states. The recent missive mirrors a similar letter that Rep. Richard Neal (D-Mass.) drafted. Neal, the chair of the House Ways & Means Committee, was instrumental in the creation and passage of the No Surprise Act and its rejection of a benchmark.

Another Insurance Company Mandate

MHA in recent months has drafted letters to health insurance companies doing business in the commonwealth objecting to their policy changes that mandate specific sites of care for the administration of certain infusion and injectable medications.
Rather than allow the treating clinician to decide what is most clinically appropriate for the patient given the patient’s medical condition, age, and living situation, or what the patient and caregiver determine is the best site of care, the insurers are making that determination.
Hospital pharmacists have told MHA they are concerned that certain medications administered in a home setting can compromise patient safety; and that other medications require dosages based on weight, same day lab tests, or require certain storage conditions, making it imperative to choose the right care site. Insurance site mandates can disrupt continuity of care, interfere with patient preferences while imposing an additional layer of bureaucracy through prior authorization requirements and navigation of scheduling at alternative locations. In addition, severe staffing shortages across the continuum of care can affect the ability of patients to obtain timely treatment if plans limit where patients can obtain covered services for infusions. 
“The steady expansion of insurance company prior authorization requirements, site-of-care directives, payment delays, and more are part of an ongoing, and expanding, slate of concerns providers and administrative staff face on a daily basis as they work to provide patient care,” said MHA’s Senior Director of Managed Care Karen Granoff.

Here are Three Insurance Bills to Improve the System

The Massachusetts legislature’s Joint Committee on Financial Services holds an important hearing tomorrow, Tuesday, November 9, beginning at 11 a.m. to review a host of bills, including some priority legislation from MHA. The committee is co-chaired by Sen. Brendan P. Crighton (D-Lynn) and Rep. James Murphy (D-Weymouth).
Among the proposed bills MHA strongly supports are:
H.1148/S.688 AN ACT TO PREVENT INAPPROPRIATE DENIALS BY INSURERS FOR MEDICALLY NECESSARY SERVICES (filed by Rep. Elizabeth Malia and Sen. John Keenan). This bill would prohibit insurers from denying payment for services solely on the basis of an administrative or technical defect in a claim. It also requires insurers to provide clarification of the reasons for claim denials, and allows providers sufficient time to re-submit curative claims. The bill establishes a 30-day timeframe for insurers to respond to provider appeals for retrospective reviews of medically necessary services. If upon review the service is deemed to be medically necessary, the insurer must reverse the denial and pay the claim.
H.1086/S.670 AN ACT RELATIVE TO UNILATERAL CONTRACT CHANGES (Rep. Michael Moran, Sen. John Velis). The bill prohibits MassHealth, the Group Insurance Commission, and commercial carriers from entering into a contract with healthcare providers that allows them to make unilateral changes to a material term or condition of such contract other than a change expressly required by law. Currently, carriers may unilaterally change the terms of the contract while it is in force, causing operational, financial, and medical consequences for both patients and providers. 
H.1086/S.670 AN ACT RELATIVE TO UNCOLLECTED CO-PAYS, CO-INSURANCE AND DEDUCTIBLES (Rep. Carole Fiola, Sen. Barry Finegold). This bill requires insurance companies, who design and sell health plans, to share accountability with providers for uncollectible patient obligations after insurance. This legislation would require insurers to reimburse healthcare providers 65% of an uncollected co-payment, co-insurance, and/or deductible that exceeds $250 if the provider does not receive payment after the provider has made reasonable collection efforts. The process for reasonable collection efforts outlined in the bill is similar to the processes that Medicare and the state’s Health Safety Net use, with the 65% reimbursement similar to the Medicare methodology.

Behavioral Health Boarding

Psychiatric boarding occurs when a patient must wait in an emergency department or medical-surgical floor until a psychiatric inpatient bed is available.
Each week MHA collects boarding numbers from hospitals across the state to share information among facilities, and to shine further light on the issue and its potential solutions.
Last Monday, there were 644 behavioral health boarding patients within 54 reporting hospitals.
Read the full report, as well as some proposed solutions, here. MHA will continue to work collaboratively with its members, partners in the behavioral health space, and the state to address the behavioral health crisis. Weekly reports are uploaded to this webpage

Executive Insights: Expanding the Circle

Tuesday, November 23; 8-8:30 a.m.

Join MHA's Executive Insights Series, which features candid interviews of Massachusetts’ healthcare leaders. We welcome you to pour a cup of coffee and start your day with us as we hear directly from the CEOs who help power our world-class healthcare community.
Jody White, president & CEO, Circle Health and Lowell General Hospital, & executive vice president, Wellforce, will join us on Tuesday, November 23 to share leadership lessons from a community-based approach to healthcare.
Register here for this last Executive Insight of 2021.

John LoDico, Editor