INSIDE THE ISSUE
Blue Cross Blue Shield Delays Controversial Policy Until Jan. 2024
Amid a massive backlash from gastroenterologists and anesthesiologists, Blue Cross Blue Shield of Massachusetts (BCBSMA) has temporarily backed off its plan to limit reimbursement for monitored anesthesia care (MAC) for endoscopies unless the patient meets certain criteria.
MAC, which fully sedates the patient, has become the standard of care for colonoscopies and upper endoscopies. The alternative is moderate sedation. Earlier this year, BCBSMA informed clinicians that after July 1, 2023, it would implement claim edits, denying coverage for MAC unless patients have certain risk factors related to age, sleep apnea, and other factors. The gastroenterology and anesthesia community, MHA, and the Mass. Medical Society, among others, emphasized that the decision would significantly affect patient care, reduce efficiency, and access, and exacerbate workforce shortages. Following the outcry, BCBSMA announced last week it would delay the policy until January 1, 2024.
The American Society for Gastrointestinal Endoscopy (ASGE) was especially critical of BCBSMA since the insurer cited ASGE’s guidelines on MAC as one of the reasons for its policy.
“Our guidelines are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any treatment,” ASGE wrote. “ASGE does not approve of its guidelines being used by BCBSMA in this manner and for this purpose. [Stress by ASGE.] Clinical decisions in any case involve a complex analysis of the patient’s condition, clinical variables, and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines for good reason and in the best interest of the patient.”
The Massachusetts Gastroenterology Association (MGA), supported by the Massachusetts Society of Anesthesiologists (MSA), argued that if BCBSMA did not want to reimburse for MAC provided to its members, while other insurers allowed it, those with Blue Cross insurance most likely would need to be scheduled on “moderate sedation days” with fewer appointment spots available. Both gastroenterology societies also said that with colon cancer being the second leading cause of cancer deaths in the U.S., the BCBSMA policy on MAC is especially poorly timed.
“The reality is that medically necessary procedures will be delayed or abandoned by patient choice because of BCBSMA program,” ASGE wrote. “Patients who are already hesitant to get the endoscopy procedure or have high-risk social determinants of health may now decide not to follow through when they are faced with the uncomfortable choice of moderate sedation versus MAC.”
MHA’s Senior Director of Managed Care Karen Granoff praised BCBSMA for engaging in a reasonable dialogue, listening to concerns, and in delaying its planned July 2023 implementation of MAC claim edits. But she noted that the insurer’s move is only a delay, not a reversal.
“It’s of great concern when the clinical expertise of highly trained physicians and care experts butt up against the administrative processes of the insurance industry,” said Granoff. “It’s a conflict we see time and time again, often with the patient unnecessarily caught in the middle.”
Spaulding Cambridge Achieves Magnet Status
Spaulding Hospital for Continuing Medical Care Cambridge has received Magnet-accreditation from The American Nurses Credentialing Center’s Magnet Recognition Program. Spaulding Hospital Cambridge becomes the second post-acute hospital and the first long term acute care hospital in New England to earn the distinction, joining a select group of just 9.4% of hospitals nationwide. Spaulding Rehabilitation Hospital Cape Cod received Magnet status in 2022.
“We are so proud of Spaulding Hospital Cambridge to be a trail blazer with this recognition by raising the appreciation of long-term acute care,” said Joanne Fucile, R.N., the interim CNO Spaulding Rehabilitation and associate CNO Spaulding Hospital Cambridge.
Spaulding is part of the Mass General Brigham system, which has two other magnet hospitals — Brigham and Women’s Faulkner Hospital and Massachusetts General Hospital. The other Magnet facilities in the state are Baystate Medical Center, Beth Israel Deaconess Medical Center, Boston Children’s Hospital, Boston Medical Center, Dana-Farber Cancer Institute, Lowell General Hospital, New England Baptist Hospital, South Shore Hospital, Tufts Medical Center, and Winchester Hospital.
It is difficult to achieve Magnet status and usually involves a multi-year process that involves a hospital-wide effort to demonstrate improvements in patient care and quality, investment in nursing staff to provide pathways to improve career opportunities, and more.
“Through all levels of Spaulding led by Joanne and her team, there was an unwavering focus on the Magnet journey,” said Ross Zafonte, DO, president, Spaulding Rehabilitation. “This designation reinforces the critical role for long-term acute level care in the healthcare field and sets Spaulding apart as a leader. I congratulate our staff that made this tremendous achievement possible.”
To learn more about the ANCC Magnet Recognition Program visit here.
#HAVHope Day Draws Attention to MHA Priority Bill
The American Hospital Association’s #HAVhope is a national day of awareness to highlight how America’s hospitals and health systems combat violence in their workplaces and communities.
In Massachusetts, hospitals are uniting to support MHA’s priority bill, H.2381/S.1538, An Act Requiring Healthcare Facilities to Develop & Implement Programs to Prevent Workplace Violence. The proposed legislation establishes a new section in the Department of Public Health (DPH) statute to require DPH to issue statewide standards for evaluating and addressing known security risks at healthcare facilities. Within six months of the issuance of guidance, hospitals must develop a workplace violence prevention plan, submit the plan to DPH, and report every 12 months each on-site instance of assault and battery, workplace violence, and aggravated and non-aggravated interference with the conduct of a healthcare facility.
A recent MHA report – An Untenable Situation & A Call to Protect the Workforce – showed that every 38 minutes in a Massachusetts healthcare facility, someone – most likely a clinician or employee – is either physically assaulted, endures verbal abuse, or is threatened. The MHA Board of Trustees in January endorsed the United Code of Conduct Principles that is included in the report, and which include measures to promote a safe and respectful environment, examples of what potential violations look like, proposed consequences for violations, and recommendations for maintaining the principles long-term.
The MHA priority bill also establishes new standards such as “aggravated interference with the conduct of a healthcare facility” and enables any employee who is a victim of assault and battery or aggravated interference to take paid leave to address criminal or other legal action.
AHA Report Focuses on Infection Prevention
A new American Hospital Association report entitled Building a Culture of Safety in Health Care is a culmination of listening sessions with nearly 350 healthcare professionals across the field regarding the state of infection prevention and control. Conversations focused on identifying challenges, sharing what’s working, improving outcomes, and creating better patient experiences.
CHIA Releases Interactive Dashboard on ED Utilization
The state’s Center for Health Information and Analysis last Thursday released a new interactive dashboard on emergency department (ED) usage that will be updated quarterly.
The current report includes data from October 2018 through December 2022, and covers data related to statewide utilization, utilization by hospital, visit characteristics, diagnoses, behavioral health, and COVID-19.
“The data source for the new dashboard and databook is CHIA’s Emergency Department Database (EDD), consisting of ED visits from all acute care hospitals in Massachusetts resulting in neither an inpatient admission nor an observation stay (treat-and-release visits),” CHIA wrote. “The data in quarterly updates are preliminary, with the primary purpose of this series to provide timely patterns and trends on key ED utilization measures.”
Board of Pharmacy: Vaccinating Even Younger Children
Throughout the pandemic, the state’s Board of Registration in Pharmacy issued directives outlining which caregivers can administer vaccines and who they could administer the shots to. The board’s most recent advisory on the issue – Board Policy 2023-02, Vaccine Administration – said certain personnel in Massachusetts could vaccinate people aged 5 and older. The directive also contemplated the end of the national public health emergency on May 11.
But between the board’s 2023-02 document and May 11, the U.S. Secretary of Health and Human Services, Xavier Becerra, issued an amendment to the so-called PREP Act for COVID-19 Medical Countermeasures, which extended some regulations about vaccine administration through December 31, 2024. That national order, citing directives from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, says qualified caregivers can administer vaccines to individuals aged 3 and older. Last week, the state Board of Registration in Pharmacy issued a notice saying that the federal directive supersedes the state directive regarding the age limitations for vaccine administration and that going forward in the commonwealth, qualified pharmacists, interns, and pharmacy technicians can give shots to those 3 years of age.
The MHA Board of Trustees, meeting last Thursday, May 25, voted to approve Sam Skura, the president of Baystate Medical Center and senior vice president of Hospital Operations for Baystate Health, as the newest member of MHA’s board. In his 25-year healthcare career, Skura served as COO of Beth Israel Deaconess Medical Center (BIDMC), and previously served as VP of Ambulatory and Clinical Services and chief administrative officer at BIDMC. He has also worked at Lahey Hospital and Medical Center and Cambridge Health Alliance, among other postings.