INSIDE THE ISSUE

> Insurer, Not MD, Determines Sedation
> Respiratory Trends
> Case Managers Agree With STAT
> Heywood’s Mental Health Unit
> 340B Case in LA

MONDAY REPORT

Insurer Limits Massachusetts Docs’ Sedation Choices

Over the objection of numerous national and local physician and medical associations, Blue Cross Blue Shield of Massachusetts (BCBSMA) on January 1 began enforcement of its controversial Medical Policy 154, which limits coverage for monitored anesthesia care (MAC) for endoscopies.

With MAC, a patient is fully sedated under the direction of an anesthesiologist when undergoing a procedure such as a colonoscopy. The alternative, which BCBSMA decided is appropriate for most patients without risk factors, is moderate sedation administered by a registered nurse. It appears that not many Blue Cross plans in other states have enacted the policy, nor have any other Massachusetts-based insurance companies. Under Medical Policy 154, patients with few or no co-morbidities, as determined by BCBSMA, will not be eligible to have MAC covered through the insurer.

In early 2023, BCBSMA informed the commonwealth’s clinicians it would impose its MAC payment policy in July 2023. Following an initial outcry, the large health insurance company agreed to delay the policy to January 1, 2024. Between July and the end of 2023, gastroenterology and anesthesiologist societies, as well as physician groups and MHA attempted to convince BCBSMA to not just delay the policy but to eliminate it.

Among the main arguments for rejecting the insurer’s new policy limiting MAC is that it comes at a time when colon cancer – the second leading cause of cancer deaths in the U.S. – is increasing among younger people. That trend combined with the fact that colonoscopies were halted for years during the pandemic means there is a significant backlog of patients awaiting tests. Because the BCBSMA policy means sedation responsibilities must shift from anesthesiologists to RNs, and because there is not only a shortage of nurses but also of nurses trained specifically in providing moderate sedation, care delays will worsen, according to the professional groups countering the insurer’s policy. The medical groups also argue that there is a longer recovery time associated with moderate sedation, meaning it takes longer to move patients through the care process, thereby reducing the number of patients that can be seen.

Although BCBSMA expanded the list of diagnosis codes that would make a patient eligible for MAC, the insurer discounted as not valid the majority of concerns expressed by physician groups both in Massachusetts and nationwide. BCBSMA also cited guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) as a reason for its decision. But ASGE has been especially critical of the insurer, saying that its guidelines were never intended to be “a legal standard of care,” and that “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 main point is that physicians – not insurance companies – should be able to determine what type of sedation is best for their patients undergoing endoscopy procedures based on the patient’s condition and other clinical variables,” said Karen Granoff, MHA’s senior director of managed care. “Leading medical groups have made it clear that Blue Cross’s policy will result in backlogs, reduced efficiency, a poorer patient experience, and could worsen staffing issues because many nurses are not trained to do conscious sedation.”

Respiratory Trends, Masking, Where to Visit

The most recent data from the last week of December shows that of the approximately 67,497 weekly ED visits, 17.8% or 12,014 were related to acute respiratory disease. Of the 14,483 hospital admissions during that week, 21.5% or 3,113, were related to acute respiratory disease.

As a result, many Massachusetts hospitals and systems facing increased numbers of patients with respiratory diseases last week began to re-impose mask mandates. Hospitals are also relying once again on Right Care, Right Place messaging to inform community members about seeking care in the appropriate settings – including outside of the ED.

“If you’re unsure where to go when you’re sick or injured, you aren’t alone,” MHA’s Right Care, Right Place website notes. “It can be difficult to know whether you should call your primary care provider, head to an urgent care center, or visit the emergency room.” The site then outlines different care scenarios.

STAT Report Confirms What Local Case Managers Suspected

STAT, the Boston-based health and medicine publication, published an investigative report at the end of December detailing how NaviHealth, a subsidiary of the large national health insurance company UnitedHealth Group, automatically denied prior authorization requests for many Medicare Advantage patients seeking rehabilitation care.

STAT received internal documents revealing “that frontline clinician reviewers were blocked from approving rehab care for most patients who lived permanently in nursing homes. Unlike other patients, their requests had to be sent straight to NaviHealth’s physician medical reviewers, who almost always denied them….” NaviHealth also automatically restricted rehab care in many cases for patients who had cognitive impairment, STAT found.

The report notes that UnitedHealth/NaviHealth denials process ended in November 2023, coinciding with increased scrutiny of Medicare Advantage plans from CMS. New rules that further limit Medicare Advantage plans’ ability to reject coverage of procedures, drugs, and tests that would otherwise be covered under traditional Medicare went into effect on January 1, 2024.

According to STAT, “The restrictions against approving skilled rehab care for nursing home residents seemed especially unfair … If someone who lived permanently in a nursing home broke her hip, went to the hospital, and then requested daily physical and occupational therapy to rehab, that case had to be directed to a physician reviewer, and, in their cases, usually were denied … If that person had lived in an apartment or house, they likely would have received care, at least until the company’s algorithm told them their time was up.”

The STAT report confirmed what many in the Massachusetts hospital community had suspected. According to Adam Delmolino, MHA’s senior director of virtual care and clinical affairs, “This story confirms what had been reported to us by our case managers throughout the pandemic and over the past year. UnitedHealth and their carve-out NaviHealth were consistently cited by case managers as the most difficult insurance company to deal with when seeking to discharge patients to post-acute care settings. Secret rules that restrict rehabilitation care for patients is an egregious breach of trust in the Medicare system, and directly causes harm to patients and their families.”

MHA’s monthly throughput surveys show that on any given day up to 1,000 patients await transfer from an acute or post-acute hospital to a skilled nursing or rehabilitation facility, or to a home health agency. Many of these patients are the ones who would have been denied transfer by the long-standing UnitedHealth policy detailed in the STAT report. Each month, the top reason case managers cite for the inability to transfer patients is: “Private insurance administrative barriers: delayed response from insurer, denial of authorization request.”

Heywood Hospital Reopens Mental Health Unit This Week

Heywood Hospital in Gardner this week is reopening six beds of a proposed 12-bed adult mental health unit that was closed in October 2021 due to a lack of qualified personnel.

In addition to the inpatient mental health unit, Heywood also operates a Partial Hospital Program that serves approximately 40 adult patients daily. The Heywood Medical Group provides outpatient psychiatric services and counseling to adult and pediatric patients, as well as school-based behavioral health services to approximately 700 students annually throughout five school districts.

Yet maintaining a mental health workforce from psychiatrist to patient sitters has been a longstanding challenge throughout the Massachusetts healthcare system.

“Delivery of mental health care services locally is essential to the overall health of our community,” said Rozanna Penney, co-CEO of Heywood. “The mental health unit operates 24/7, requiring the staffing of professionals for all three shifts. We offer sign-on bonuses, flexible scheduling, tuition reimbursement, and competitive salaries, and are seeking individuals with the desire to make a difference in our community.”

340B Case in Louisiana Hinges on Type of Pharmacy Dispensing Drugs

An important 340B drug discount case is underway at the U.S. District Court in Louisiana, and at the end of last year the American Hospital Association joined with the Louisiana Hospital Association (LHA) and other interests to file a friend of the court brief in the case.

Under the 340B program, drug companies that participate in Medicaid and Medicare Part B must provide drug pricing discounts to eligible hospitals. The drug companies in Louisiana had always provided the discounts for drugs dispensed through both in-house pharmacies and community pharmacies. But according to the suit, in July 2020, one of Pharmaceutical Research and Manufacturers of America’s (PhRMA’s) members “suddenly refused to provide these discounts for one of its drugs if dispensed to 340B patients at community pharmacies (or ‘contract pharmacies’), later expanding this new policy to cover essentially all of its drugs. Recognizing an opportunity to pad its profits, AstraZeneca [Pharmaceuticals LP] quickly followed suit, as did 27 other major drug companies.”

Hospitals in the Pelican State were harmed by the move. Fewer than half have in-house pharmacies and are forced to contract with community pharmacies. They claimed that by losing 340B drug discounts they were unable to pass discounts on to patients, and had to cut services. In response, the Louisiana Legislature passed, 135-2, the “Defending Affordable Prescription Drug Costs Act” that prohibited drug companies from distinguishing between in-house and community pharmacies. The drug companies then sued, resulting in the current case.

The AHA and LHA brief argues that the state law does not preempt the federal 340B law, as the drug companies argued, but rather it “furthers Congress’ goal in enacting the 340B program: to enable hospitals to ‘stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.’”

John LoDico, Editor