INSIDE THE ISSUE
A Clogged System: 1,200 Patients Awaiting Discharge from Mass. Acute Care Hospitals
A new MHA report, A Clogged System: Keeping Patients Moving Through their Healthcare Journey, reveals that nearly one out of every seven medical-surgical beds—15% of those in the state—is currently occupied by patients who no longer need to be in an acute care hospital. Approximately 1,200 patients are “stuck” in hospital beds as they await discharge to a post-acute care facility, a community-based setting, or a psychiatric unit.
The resulting backups mean patients who are awaiting post-acute care placement are not receiving the specialized treatment they need, and patients who require hospital-level care are forced to wait longer in emergency departments until the bed they need is available. This often-overlooked issue has resulted in a clogged healthcare system that causes longer hospital wait times, care access challenges, and an increasingly strained workforce.
“Even as the public health emergency has come to an end, our healthcare system is still in major distress,” said Steve Walsh, president & CEO of MHA. “This backlog of stuck patients is playing a major role in driving up wait times and obstructing access to care. We saw a tremendous level of collaboration across healthcare throughout COVID-19, and it will take that same level of focus to resolve capacity issues. MHA and our members look forward to our continued work with partners throughout the care continuum and in state government to strengthen the commonwealth’s world-class healthcare system for every patient in need of timely care.”
MHA found that the reasons for delayed discharge to post-acute care settings, as reported by hospital case managers, include the following:
- Private insurance administrative barriers
- Capacity/staffing constraints at post-acute care facilities
- Lack of guardianship/conservatorship/healthcare proxy
- Lack of secondary insurance
- Need for specialized behavioral health/substance use disorder services
- Inadequate insurer post-acute care networks
- Need for specialized medical services
- Lack of access to necessary community services
- COVID status
- Unvaccinated status
“Hospital case managers are spending endless hours and dozens of phone calls trying to get patients to the next level of care they need.,” said Amanda Ford, R.N., director, Continuity of Care at Lowell General Hospital. “But the obstacles have become so numerous and so intense that it sometimes feels like an impossible task. We want to share a glimpse into this crisis and the solutions that have been identified from those of us on the front lines of patient care.”
The report includes recommendations on steps that Massachusetts can take to create a more seamless patient journey and free up acute-care beds, particularly when it comes to long-term care placements. These proposed solutions include increasing access to long-term care beds, dementia beds, and geriatric-psychiatric beds; expanding the Hospital to Home Partnership Program; and improving processes to expedite guardianship, conservatorship, and healthcare proxy cases through the courts.
“The collaboration between Massachusetts hospitals and post-acute care providers remains at an all-time high,” said Cindy Page, chief executive officer of Encompass Health Rehabilitation Hospital of Braintree, and chair of MHA’s Continuum of Care Council. “With help from state leaders, we have been working daily to improve patient transitions and to ease capacity constraints across all healthcare settings. But, as this report shows, more help is needed to address the factors that are beyond our control.”
There are several efforts already underway to address patient flow and improve hospital capacity for patients in need of post-acute care. In partnership with healthcare providers, state agency-driven initiatives include the Skilled Nursing Facility Short-Term Rehab Capacity Program, a temporary program adding short-term rehabilitation capacity to all regions of Massachusetts; and the Post-Acute Care Transitions Collaborative, which meets monthly to serve as a forum where hospitals case managers can escalate and address challenges with skilled nursing facility placements.
The Compass Closure: Guidance from State Government
As reverberations from the abrupt closure of the Compass Medical physician practice continue, the state created this website last week for affected patients and providers. It directs former Compass patients to health centers, urgent care centers, and potential new practices able to accept them. It also contains resources on where to file complaints, and information for providers about their responsibilities.
For example, the state ’s Board of Registration in Medicine informed former Compass M.D.s that they have a “responsibility to ensure continuity of care for your patients,” and warned them that “Massachusetts law has recognized that ‘A physician who has undertaken to render medical services violates his duty of care if he abandons his patient or fails to take steps called for by good medical practice.’ ”
The Board of Registration in Pharmacy last week issued a directive allowing pharmacists to provide up to a 30-day supply of Schedule VI medications. Schedule VI is a Massachusetts designation for prescription drugs that have a low probability for addiction and not covered by the federal Schedule II-to-V designation, which rates prescription drugs from most-to-least addictive. (Schedule I denotes illegal drugs, such as LSD and heroin.) Schedule VI drugs include ibuprofen, penicillin, and cimetidine, among others. Only Schedule VI drugs that do not require reporting to the state’s Prescription Monitoring Program may be dispensed in 30-day supplies. The pharmacy board said permitting the 30-day supply will allow Compass patients to make alternative care arrangements.
Pharmacists should direct individuals in need of an immediate bridge prescription for buprenorphine (Suboxone, Subutex) and/or linkage to care due to the closure of Compass Medical, to call the free MA Addiction Warmline (617) 414-4175 for an immediate prescription and referral to ongoing care. For a referral to substance use disorders treatment, visit helplinema.org or call 1-800-327-5050.
In an effort to get the health insurance industry more involved with the COVID-19 response, the state’s Division of Insurance issued its first bulletin of the year, directing the insurers to authorize – and reimburse – Acute Hospital Care at Home programs.
HPC Addresses Prior Authorization
As noted in MHA’s recent report (see above), among the greatest contributing factors to capacity constraints and access problems are private insurance administrative barriers, including delayed responses and denial of authorization requests.
The Health Policy Commission (HPC) last Wednesday addressed the need to reduce unnecessary administrative complexity in the healthcare system, including prior authorizations. “The unnecessary complexity associated with prior authorization [PA] directly impacts patients,” the HPC wrote in its summary of the issue. “For example, patients may experience delays in care while PA requests are being submitted and processed, even when their requests are ultimately approved.”
Among the problems the HPC identified with prior authorizations is the fact that insurers often update their PA policies mid-year, and on different timelines, “without a grace period to allow providers to update their systems.” Lack of standardization between plans, retroactive denials, and delays in reaching PA decisions were also cited as problems.
While PA can decrease use and associated spending on medical imaging and unnecessary pharmaceutical use, overall, the HPC found, “complexity and variation in PA processes contributes to inefficiency and unnecessary spending” as well as physician burnout.
The HPC noted ongoing federal and Massachusetts efforts, including MHA-endorsed legislation, H.1143 and S.1249, An Act to Improve Health Insurance Prior Authorization and An Act Relative to Reducing Administrative Burden, filed by Rep. Jon Santiago (D-Boston) and Sen. Cindy Friedman (D-Arlington), respectively. to reduce prior authorization burdens. The bills, supported by MHA, the Massachusetts Medical Society, and Healthcare For All, would reduce administrative burden around prior authorization, address medical necessity, utilization review guidelines, increase transparency, improve access for patients, and hold health plans accountable. The HPC has been working with Network for Excellence in Health Innovation (NEHI) and the Massachusetts Health Data Consortium (MHDC) on strategies to automate PA to reduce provider uncertainty, decrease the time needed for approval or denial, and reduce paperwork, among other benefits. In the discussion that followed the HPC staff’s presentation, it was generally agreed that legislative action would be needed to move the needle on prior authorization reform.
Trahan Sponsors Legislation to Address Next Pandemic Threat
U.S. Representatives Lori Trahan (D-Mass.) has joined Reps. Michael Burgess (R-Tex.), Dan Crenshaw (R-Tex.), and Susie Lee (D-Nev.) to introduce the Disease X Act of 2023, aimed at assisting the United States in developing medical countermeasures to combat future pandemics.
“It’s been over three years since the COVID-19 pandemic began wreaking havoc on our nation, and yet we still have no sustained funding, program, or strategy dedicated to accelerating the development of countermeasures for unidentified infectious diseases,” said Trahan, co-founder of the bipartisan Congressional Pandemic Preparedness Caucus and a member of the House Energy and Commerce Committee’s Health Subcommittee.
The legislation would create a “Disease X” medical countermeasures program for unknown viral threats with pandemic potential at the Biomedical Advanced Research and Development Authority (BARDA). Specifically, it would direct BARDA to accelerate and support the countermeasure program and allow U.S. Health and Human Services to award contracts, grants, and cooperative agreements, or enter into other transactions, to promote the development of Disease X medical countermeasures for viral families with pandemic potential. Background on the Disease X program is here.
Save the Date: Tenth Annual CARe Forum, Sept. 29
The Tenth Annual Communication, Apology and Resolution (CARe) Forum led by the Betsy Lehman Center takes place on Friday, September 29, 2023, from 9 a.m. to 1 p.m. The forum was originally scheduled to take place this month but was postponed. Registration is free and will open at the end of the summer. For those who are unable to attend in-person, there will be an option to join virtually. Add the new date to your calendar and contact CARe Program Director Melinda Van Niel (Melinda.VanNiel@betsylehmancenterma.gov) for more information.
Apply for AHA’s Quest for Quality Prize
The American Hospital Association has opened nominations for its 2024 Quest for Quality prize that honors hospitals and health systems committed to leadership and innovation in improving quality and advancing health. Applicants should provide access to exceptional quality, safe, and patient- and family-centered care; partner with other community organizations and agencies to improve the health status of their communities and address disparities; and develop new and innovative models of care. The AHA Quest for Quality Prize will honor one winner, up to two finalists, and up to two Citation of Merit recipients. Submissions are due by Tuesday, September 12.
Win Brown, the president and CEO of Heywood Healthcare for the past 12 years, is leaving his post. The system announced that it will now be led what it called an “untraditional model” of co-CEOs – Rozanna Penney, the current V.P. of patient care services, chief nursing officer, chief operating officer, and executive director of Heywood Medical Group; and Tom Sullivan, the current V.P. of financial services. With his departure from Heywood, Brown will also vacate his current post on the MHA Board of Trustees. Throughout his long association with MHA, Brown provided valuable insight into the special challenges faced by independent hospitals with high public-payer patient populations. During the early days of the pandemic, he took the unique step of instituting a series of video updates to help educate Heywood’s service area and allay concerns.
Health Policy Commissioner Don Berwick, M.D., announced last week that he will be leaving the HPC after seven years of service. Berwick was appointed by then Attorney General Maura Healey in 2015 as the HPC’s consumer advocate. Berwick co-founded the Institute for Healthcare Improvement and led the organization for nearly 20 years. He served as administrator of the Centers for Medicare and Medicaid Services for a brief period during the Obama Administration and was a Democratic candidate for Massachusetts governor in 2014.