INSIDE THE ISSUE

> PATHways Promotes Hospital to Home
> Setting the Benchmark
> Improving CMED
> New IRE for Medicare Advantage
> Transitions

MONDAY REPORT

HPC’s PATHways Program Promotes Hospital-to-Home Transitions

Responding to a patient “throughput” problem that MHA has been tracking for the past four years, the Health Policy Commission (HPC) last Thursday announced that it was making funds available for acute care hospitals that have, or will create, hospital-to-home programs.

“Throughput” refers to a patient moving through the healthcare system from one care site to another, such as when a patient is treated at an acute care hospital and then transitions to post-acute rehabilitation, or recovers at home. The problem that MHA has been tracking with monthly throughput surveys since March 2022 is that as many as 2,000 patients per month remain hospitalized despite being ready for discharge. The Massachusetts Transitions from Acute Care to Post Acute Care (TACPAC) Task Force amplified the problem in its white paper last year.

Patients remain “stuck” in inpatient beds for a variety of reasons, including a shortage of healthcare workers needed to staff licensed beds in post-acute facilities; the lack of 24/7 insurer availability to authorize transfer requests; or patients lacking healthcare proxies, care directives, and other alternatives to guardianship and conservatorship so their wishes can be carried out promptly if they are incapacitated – without involving the courts. The backups that occur due to stuck patients reverberate through the system, resulting in, among other problems, patients boarding in emergency departments (EDs) because they can’t get an inpatient bed that is currently occupied, or people delaying care because they don’t want to wait in backed-up EDs.

In response, last Thursday the HPC, following one of the recommendations of the TACPAC Task Force, issued a Request for Proposals for the Promoting Appropriate Transitions to Home (PATHways) program, which will distribute $1.89 million over two and a half years to hospitals. Seven awards of up to $210,000 each will be distributed from the Distressed Hospital Trust Fund to 26 eligible hospitals, while two other awards of $210,00 each will be available to all hospitals. Each awardee will be required to contribute at least 30% of the total budget amount in-kind. Eligible hospital programs will partner with Aging Services Access Points (ASAPs), which are organizations designed to connect residents over the age of 60 and their caregivers with programs and services to help them age in the community.

The program builds upon the previous Hospital-to-Home Partnership Program that the state funded with ARPA dollars during the pandemic. That program embedded ASAP case managers with hospital discharge teams and enabled discharges to the home for those patients who needed additional supports to remain in their homes.

“Given our hospitals’ ongoing capacity constraints, we are grateful to the Healey-Driscoll administration and the HPC for their responsiveness and support for the safe, efficient care transitions that patients deserve,” said Adam Delmolino, MHA’s senior director of virtual care & clinical affairs. “These are powerful partnerships. Following a successful pilot program in conjunction with Mass Aging Access, we are confident that the PATHways program will continue to allow hospitals and ASAPs to help patients recover in the comfort of their own homes, open up care beds for others, and provide people with a range of resources in their communities.”

The RFP is open until June 4. The HPC will hold a virtual information session on the funding opportunity on April 29 from noon to 1 p.m.

Benchmark Data Provides Answers, Raises Questions

The focus last Wednesday was on the healthcare cost growth benchmark, the voluntary target for the annual growth of “total healthcare expenditures” – meaning the sum of all public and private spending for health services in the state.

As part of the regulated process for determining the annual benchmark, the Health Policy Commission (HPC) met last week with members of the legislature’s Joint Committee on Health Care Financing to hear reports from data analysts and the public. The benchmark hearing follows the previous step in the process – the setting of the state’s potential gross state product (PGSP) in January. For 14 years, ever since the benchmark process was created in 2012, the PGSP always has been set at 3.6% despite economic changes over the years; and the healthcare cost benchmark has always defaulted to the PGSP as the basis, including a five-year period with a statutory requirement for the benchmark to be set at 0.5% below PGSP. The benchmark itself will be voted on at the HPC’s next full meeting on April 16.

At last week’s meeting, the Acting Executive Director of the Center for Health Information & Analysis (CHIA) Andrew Jackmauh and the HPC’s Senior Director of Research and Cost Trends David Auerbach delved deep into the data to present very granular information on healthcare costs. While they touched briefly on administrative waste (often projected to cost the Massachusetts system over $1.75 billion a year) and fast-growing pharmaceutical costs, much of their presentation focused on hospitals.

The data in many instances was compelling, but often generated more questions than answers. For instance, outpatient hospital costs rose significantly over a period of time, but that often reflects that care is shifting from higher-cost inpatient settings – which could be considered a good, cost-cutting measure. Pharmaceutical costs have spiked, but do the very expensive GLP-1 drugs that are wreaking havoc with municipal finances help people maintain their weight and avoid costly cardiac and other health problems down the road?

Auerbach discussed how it appears that providers are using higher priced care “sometimes in place of lower-priced alternatives.” He pointed specifically to the use of cardiac ablation in the management of atrial fibrillation. In that minimally invasive procedure using catheters, physicians create small scars in heart tissue to block faulty electrical signals. The cost of the procedure, as Auerbach noted, can run from $28,000 to $86,000. He said in some procedures an incentive may exist to use a higher cost procedure “and it’s hard to resist.”

But missing from Auerbach’s presentation was any indication if cardiac ablation was used only after other, cheaper alternatives were first tried. Nor did it show the success rate of the procedure, which has been proven to be more than 90% effective. As one legislator pointed out, the hearing did not include analysis of what the state is actually receiving for the money that is invested in the healthcare system. Reports have shown that Massachusetts is the top ranked state in the nation for the provision of high-quality healthcare.

In his testimony to the HPC and legislators, MHA’s Senior Vice President of Healthcare Finance & Policy Dan McHale attempted to show the “two realities” hospitals are facing “as they are caught between the urgent needs of their patients and workforce and the need to invest and prepare for the future. They are caught between the demands of affordability and the mission of accessibility. And they are caught between a benchmark process that was intended to align with the state economy but is unfortunately no longer tied to that reality.”

While McHale stressed the need for urgency and collaboration to address the affordability issue, especially as the healthcare system braces for hundreds of thousands of patients to lose coverage in the coming years, he noted that the 2024 data that is being used to set the current benchmark also shows that hospitals faced a $200 million deficit in the Health Safety Net and that 74% of hospital systems lost money in their operations during that year.

As for the stagnant 3.6% benchmark, McHale said it bears no relation to state economic activity or the realistic growth of the sector, thereby weakening Massachusetts’ ability to accurately assess and discuss the state of healthcare costs. “For fourteen years in a row, PGSP has been set at 3.6% with no apparent connection to actual economic growth in the state,” he said. “We argue it is time to break this cycle and create a modernized benchmark that aligns with actual economic conditions.”

HPC Executive Director David Seltz stressed that each year state officials review “up-to-date” data and forecasts to set the PGSP, which McHale noted nonetheless has resulted in the PGSP always being set at the same percentage – or 3.6%. Massachusetts Gross Domestic Product (GDP) growth has averaged 5.2% for the past 10 years; in seven of those years, the actual state GDP growth has exceeded the PGSP amount – and therefore also the healthcare cost benchmark, according to testimony that MHA submitted to the HPC.

In response to a comment from Rep. Tommy Vitolo (D-Brookline), who argued that regardless of the actual benchmark, the state should remain focused on improving outcomes and driving down costs, McHale said, “We completely agree with that statement … The reality should be what patients are paying out of pocket and that’s the work we have to do collectively. And hospitals have a major role in that, in terms of addressing costs, in terms of the settings [where care is provided], in terms of supporting their workforce, in terms of bending the curve – we’re entirely supportive of that.”

Big Events This Year Demand Good Communication

The World Cup in Foxborough. The 250th anniversary of the Declaration of Independence. The arrival of the Tall Ships in Boston Harbor in July. FANEXPO Boston, which will bring 55,000-plus gamers, cosplayers, comic book fans, and others to Boston in August – not to mention large boisterous championship celebrations if Boston’s professional sports teams are successful.

All of these massive events are putting the state’s emergency preparedness sector – including the hospital community – on alert. Hospitals are working closely with the state and in coordination with each other to prepare/for emergency preparedness. One component of that alert system is the Central Medical Emergency Direction (CMED) system in the commonwealth that links ambulance and emergency medical services with healthcare facilities and other key entities.

Recently, DPH issued a Request for Information to seek input on the future of CMED, which among other things is used for Mass Casualty Incident (MCI) patient destination coordination. DPH wants to know, among other things, if CMED is used for routine communications between EMS and hospitals and, if not, what other communication systems are used. Are there technical issues using CMED? Should there be regional or statewide plans governing its use? Is its funding sufficient? DPH is asking that responses to these and other questions be sent to it by April 13.

CMS Picks New Entity for Medicare Advantage Appeals

The Centers for Medicare & Medicaid Services (CMS) has changed the company that is responsible for conducting appeals of adverse reconsiderations by Medicare Advantage plans.

Effective May 1, C2C Innovative Solutions will take over the appeals process from the current “independent review entity (IRE)” – Maximus – which will still process appeals requests through April 30. CMS said there may be a brief period when both C2C and Maximus are issuing decisions.

When a Medicare Advantage plan issues an adverse reconsideration, the case file is sent to the IRE, which uses its own doctors and health professionals to review the medical necessity of the appeals request. The IRE does not work for the health plan. Data indicates that IRE decisions for Medicare Advantage (also known as Medicare Part C) appeals have been overwhelmingly favorable to insurers, with IREs frequently upholding denials, particularly for specific services. Beneficiaries whose appeals have been rejected by an IRE may then appeal to an administrative law judge.

Transitions

Jonathan Lind has been named the new president of Beth Israel Deaconess Hospital – Plymouth, effective May 4. He replaces Kevin Coughlin, who has led the hospital since 2016. Lind comes to Plymouth from his position of president of Endeavor Health Swedish Hospital in Chicago. Lind earned a bachelor’s degree in psychology from Dartmouth College and received an MBA from the University of Chicago’s Booth School of Business.

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The Massachusetts Medical Society has named Theodore (Ted) Calianos II, M.D., as executive vice president and CEO, effective June 1. He succeeds Lois Dehls Cornell, who served as MMS CEO for the past 10 years. Calianos comes to MMS from Cape Cod Healthcare, where he recently served as the chief medical officer of Falmouth Hospital. He was also medical director and plastic surgeon at Cape Cod Healthcare/Medical Affiliates of Cape Cod. Calianos served as MMS president from 2020 – 2021. He earned his medical degree from the University of Texas Medical Branch.

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VNA Care has appointed Salvatore (Sal) Perla as president and CEO, effective today. Perla was previously president and CEO of Nashoba Valley Medical Center and then Norwood Hospital, and prior to those roles, he spent 13 years at Milford Regional Medical Center where he served as vice president of operations. Most recently, Perla served as interim CEO at Lower Keys Medical Center in Key West, Florida, and as a director at Synergetics Worldwide Healthcare, a consulting firm. An epidemiologist by training, he holds a Doctor of Public Health from Capella University, a Master of Arts in Healthcare Administration from Framingham State University, and a Bachelor of Arts in Health Science from Northeastern University.

John LoDico, Editor