INSIDE THE ISSUE

> MHA Report: A Historic Health Equity Commitment
> Concern Over March 31 Deadline
> New Federal Prior Auth Rules
> High School-to-Provider Pipeline
> Death Registrations
> Milford Regional/UMass Memorial Health

MONDAY REPORT

New Report Covers First Year of Historic Equity Waiver

The approach centers on several priorities: comprehensive data collection to better identify care disparities, screening for the supports patients may need in their everyday life, improving access for patients with disability and/or translation needs, and building new partnerships across the care continuum. It also is driven by results: hospitals can only access funding once they satisfy the commitment’s rigorous goals.

More specifically, hospitals and MassHealth are collecting data on patients’ race and ethnicity, along with information about their language, disability status, sexual orientation, and gender identity. Hospitals must also demonstrate meaningful improvement on rates of screenings for patients’ health-related social needs (such as nutrition, housing, and transportation needs) throughout the five-year journey. Hospitals will be assessed on their performance and demonstrated improvements on access and quality metrics, including reductions in health outcome disparities. And they will also be establishing clinical partnerships with accountable care organizations and clinical partners, with a specific focus on improving care quality and reducing disparities.

Massachusetts hospitals are contributing a total of $875 million over the five-year commitment to help finance a new Quality and Equity Initiative Program (HQEIP). With the a match from the federal government, a total of $2.2 billion in health equity incentive funding will be available for acute care hospitals to earn over the course of the waiver. The commitment is unique in that 100% of the funding must be earned based on performance of identified metrics with no direct funding available simply for implementation. In addition to the funding that is available at the statewide level, each hospital’s share of the available funding will be dictated by their individual performance on key quality and equity measures. Hospitals will be evaluated both on meeting certain performance benchmarks as well as their improvement from the previous year.

“Following this five-year process, Massachusetts will know more about the state’s health equity needs than ever before,” the MHA report states. “Most importantly, its providers will have achieved the goal of reducing disparities through culturally competent care. Taken together, the measures within this commitment will fundamentally change and improve interactions between providers and patients at the point of care. They will make sophisticated equity efforts a universal, expected part of the healthcare experience.”

The first year of the waiver program, 2023, saw the beginnings of the foundational work to implement and evaluate hospitals’ new health equity efforts. Throughout the past year, hospitals completed numerous elements of the commitment, including the completion of a detailed assessments of how they currently collect patient demographic information and establishing a process to share data with the Center for Health Information and Analysis; preparing a plan for screening MassHealth patients for health-related social needs in inpatient acute settings using a standardized tool; forming a total of 57 “joint accountability partnerships” with ACOs; and creating a health equity strategic plan that details hospitals’ health equity goals and their process for assessing the needs of their community. Each succeeding year of the waiver brings more measurable responsibilities with strict oversight from the state.

In 2023, The Joint Commission incorporated six new health equity elements as part of its triennial accreditation reviews. As part of the waiver program, all Massachusetts acute care hospitals were evaluated for adherence to the TJC health equity guidelines whether or not they were up for their triennial accreditation. All were found to be in compliance, making Massachusetts the first state in the nation to achieve the TJC health equity standards. Beginning this year, hospitals are preparing to meet TJC’s health equity certification standards – a more advanced level of expectations.

“This is a generational effort to improve the lives of patients – particularly those who have been historically marginalized from the healthcare system,” said MHA President and CEO Steve Walsh. “Our hospitals, health systems, and state government are holding themselves accountable for closing disparities and embracing the massive changes it will take to provide everyone with the care they deserve. It would not be possible without the leadership of EOHHS and state officials. We thank our partners at the state for bringing this commitment to life and working closely with healthcare providers every step of the way.”

Deadline on Graduate Nurses Approaches Quickly

Hospitals, health systems, post-acute care facilities, and the entire healthcare system are nervously watching the calendar, anticipating a fast-approaching deadline that will reduce the availability of much-needed nurses.

On March 31, a regulation that allows a graduate of a nursing program or nursing students in their last semester of study to work at the bedside under direct supervision, but before they take get licensed by the state, will expire. The flexibility was put in place during the pandemic and extended by Governor Maura Healey through an appropriations bill.

Graduate nurses still must take the National Council for Licensure Exam-RN (NCLEX-RN), and they still must be licensed through the Board of Registration in Nursing. But allowing them to practice in the months before they are formally certified not only helps the new nurses get real-life experience, but helps the healthcare system, and the patients it serves, that is beset by record workforce vacancies. Since the flexibility was first allowed, nurse leaders have cited the innovative approach to professional development as being an especially beneficial workforce and patient care tool.

A bill, H.3613, An Act to Improve Healthcare Development Through Graduate Nursing Practice, would erase the March 31 deadline and allow the new nurse flexibility to stand. It has been moving through committees throughout the session, but its passage becomes urgent as the March deadline nears.

Along with MHA, the Organization of Nurse Leaders, and other health advocates, the Massachusetts Senior Care Association is a strong supporter of H.3613. Workforce shortages in nursing homes is just one component of a multipart capacity problem that makes it difficult to transfer patients from acute care hospitals to post-acute services.

“The commonwealth’s nursing facilities are operating in the midst of a historic workforce shortage, with more than 2,300 licensed nursing positions vacant,” said Tara Gregorio, president of the Massachusetts Senior Care Association. “Enactment of this bill would help to address the acute nursing shortage by making permanent a vital workforce policy, adopted by the Legislature, allowing graduate nurse and nursing students attending the last semester of a registered nursing or practical nursing program to practice nursing – thereby ensuring continued access to timely, quality care, while offering immediate support to our exhausted caregiving teams.”

CMS Issues Final Prior Authorization Rule

The Centers for Medicare & Medicaid Services last week released the prior authorization final rule that is most noteworthy for requiring some health insurers – not all – to make prior authorization decisions on medical items and services within 72 hours for urgent requests and within seven calendar days for standard requests.

While providers have welcomed the overall federal effort to refine the prior auth process, many expressed disappointment with the limitations of the rule. Karen Granoff, MHA’s senior director of managed care, said, “Waiting three days for a health insurance company to decide if it will approve and pay for a procedure that is considered urgent is still too long. And waiting up to a full week to learn if a non-urgent service will be authorized is unacceptably long for a patient who is seeking relief from a medical problem. By contrast, Massachusetts insurance law requires that prior authorization requests be acted upon within two business days or within 24 hours when the decision relates to an urgent request for prescription medications under step therapy protocols.”

Under the rule, insurers will also have to provide a specific reason for denying a prior authorization request, which will help patients and providers with appeal requests, and will be required to post certain authorization metrics on their websites, including which services require prior authorizations, the number of denials and approvals, and the denials overturned after appeal.

The new rule goes into effect in two years (January 1, 2026) and does not apply to employer-sponsored insurance plans, which by some estimates cover about 150 million people in the U.S. The CMS rule is tailored to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges.

The final rule is also noteworthy in that it requires insurers to create application programming interfaces (APIs) to improve the electronic delivery of its prior auth decisions to patients, providers, and to other insurers. The payer-to-payer info sharing is important, CMS says, as it “will help improve care continuity when a patient changes payers and ensure that patients have continued access to the most relevant data in their records.” Requiring a standardized API will also allow providers and payers to automate the end-to-end prior authorization process by identifying documentation requirements for prior auth approval and supporting a prior authorization request and response.

The API requirements must be implemented by January 1, 2027.

In Massachusetts, some plans have unilaterally reduced the list of procedures requiring prior auths. This month, insurers, hospitals, and nursing homes voluntarily agreed on a plan whereby the insurers would waive prior authorizations for admissions from acute care hospitals to post-acute care facilities across commercial, Medicaid, Medicare, and Medicare Advantage lines of business.

Hospitals need help with their staffing and public schools need help with their funding. Last week, Bloomberg Philanthropies announced a program that may help fulfill both of those needs – a $250 million initiative that will bolster health-related education programs in public schools and send graduates directly into well-paying healthcare jobs.

Boston is one of 10 cities that will benefit from the program. Bloomberg devoted $38 million to Boston Public Schools, with the money directed to BPS’s Edward M. Kennedy Academy for Health Careers. With the funding, the academy will double in size to 800 students and add new programs. Upon graduation, students can pursue higher education or graduate directly into careers within the Mass General Brigham system.

A Win-Win for Boston Public Schools, MGB, and Healthcare

Hospitals need help with their staffing and public schools need help with their funding. Last week, Bloomberg Philanthropies announced a program that may help fulfill both of those needs – a $250 million initiative that will bolster health-related education programs in public schools and send graduates directly into well-paying healthcare jobs.

Boston is one of 10 cities that will benefit from the program. Bloomberg devoted $38 million to Boston Public Schools, with the money directed to BPS’s Edward M. Kennedy Academy for Health Careers. With the funding, the academy will double in size to 800 students and add new programs. Upon graduation, students can pursue higher education or graduate directly into careers within the Mass General Brigham system.

“As healthcare providers continue to face persistent labor challenges, it is crucial that we develop innovative partnerships to respond to the challenges of today and invest in the healthcare leaders of tomorrow,” said Anne Klibanski, M.D., president and CEO, Mass General Brigham in Boston. “Moreover, our work to dismantle generational health inequities depends on our ability to recruit, retain and support a diverse, culturally competent and highly skilled workforce. We are deeply grateful to Bloomberg Philanthropies for their transformational support that will allow us to dramatically increase the impact of our proven partnership with the Edward M. Kennedy Academy for Health Careers and for our continued collaboration with Mayor Wu, the City of Boston and Boston Public Schools.”

Bloomberg Philanthropies was founded by Michael R. Bloomberg, the investor and former three-time mayor of New York City. Bloomberg grew up in Medford, Mass. and has given away more than $17 billion to educational programs.

Massachusetts Has New System for Death Registrations

The process for certifying and registering a death in Massachusetts is changing in April and medical certifiers – that is, physicians, nurse practitioners, or physician assistants – must be trained in the new system. Others involved in the death registration process – from town clerks to Boards of Health burial agents, those in long-term facilities, funeral directors, etc. – also must be trained in the new Massachusetts Vital Records Information Collaborative (MAVRIC).

The current Vitals Information Partnership (VIP) system uses a cumbersome manual documentation process. MAVRIC is digitally based with an easier, user-friendly interface to the state’s secure records and statistic system. The death registration transition is part of a larger effort to eventually move all vital record submissions to the digital platform.

All medical certifiers and pronouncers will need training to use MAVRIC and that training will begin in February through the online TRAIN Massachusetts platform. For a list of FAQs about MAVRIC, click here.

Milford Regional & UMass Memorial Health on Path to Merger

Another free-standing independent Massachusetts hospital is on the verge of being subsumed into a system with the announcement last week that Milford Regional Medical Center and its physician group have signed a definitive agreement to become a member of the UMass Memorial Health system.

The signed agreement follows a non-binding letter of intent in September 2023, and sets into motion what is expected to be a nine-month process to get the regulatory approvals to make the deal final.

The 148-bed Milford Regional is led by President & CEO Edward Kelly. In 1991 it became the first hospital to clinically affiliate with UMass Memorial Medical Center. The UMass Memorial system is led by President & CEO Eric Dickson, M.D.

“Healthcare organizations across the state and nation continue to face extreme financial, staffing and operational challenges, and these issues are most acute for community hospitals,” said UMass Memorial Community Hospitals President Douglas Brown. “We are confident that a corporate affiliation is the best way to ensure local access to high-quality care for patients and ongoing investment in technology and workforce development in support of the Milford Regional community.”

John LoDico, Editor