INSIDE THE ISSUE

> Prior Authorizations
> MHA to CMS: Strong Waiver Approval
> Maternal Health Advisory Group
> Capacity Concerns Across Mass.
> Boarding Affects Clinicians
> ACHE of Mass. February Program
> Transitions at North Adams

MONDAY REPORT

Series of Bills Focus on Reducing Prior Authorization Burdens

As informal legislative sessions continue through the end of 2023, several important bills focusing on the prior authorization process are currently before House-Senate joint committees.

Reducing Administrative Burdens

One bill that will be heard today before the Joint Committee on Mental Health, Substance Use and Recovery, chaired by Sen. John Velis (D-Westfield) and Rep. Adrian Madaro (D-Boston), is S.1249, An Act Relative to Reducing Administrative Burden, from Sen. Cindy Friedman (D-Arlington). S.1249, which had a hearing before the Financial Services Committee in September, would require insurers to respond faster to prior authorization (PA) requests; prohibit PAs for services, medications, and treatments that have historically low denial rates; and require a PA to be valid for the duration of treatment instead of having to be constantly renewed when the patient’s condition hasn’t changed, among many other practical, time-and cost-saving measures.

The Massachusetts Medical Society and Health Care For All join MHA as the lead proponents of the proposal.

Hospitals are not against eliminating prior authorizations, which have a proven ability to rein in wasteful care. Rather the goal of S.1249 is to reform the authorization process to reduce clinician burnout, remove delays in access to care, and take waste out of the system. Recently, Blue Cross and Blue Shield of Massachusetts announced it was eliminating 14,000 authorizations from the system by ending prior authorization requirements for home care services. This will allow hospitals to expedite discharges, free up beds, and get patients home quickly to continue treatment.

“Patients need solutions that remove unnecessary barriers to their care, control their costs, and alleviate the pressures on their caregivers,” said MHA President and CEO Steve Walsh. “This legislation gives Massachusetts a way to address all three of those priorities while opening up beds for those who need them most.”

“Reforming prior authorization policies is critical to ensuring that providers can deliver quality care to their patients, while keeping costs down,” said Senator Friedman. “Administrative burden is one of the highest contributing factors to burnout – something that is happening at an alarming rate among our healthcare providers. It is of the utmost importance and urgency that we provide relief to them, and this legislation is a very important place to start that work.”

A recent MHA report showed how wasteful administrative spending and insurance company red tape — including burdensome prior authorizations — costs the healthcare system $1.75 billion annually.

Behavioral Health Access

Also today, the Joint Committee on Mental Health, Substance Use and Recovery will hear testimony on another MHA priority bill, S.1267, An Act Expanding Access to Mental Health Services, from Sen. Jake Oliveira (D-Ludlow). The bill builds on the Mental Health ABC Act by expanding the number of behavioral health settings that insurers must cover without prior authorization; these expanded sites include the newly established youth crisis stabilization services and behavioral health crisis evaluations delivered in emergency departments as part of the administration’s Behavioral Health Roadmap. In addition, S.1267 aligns the approval process for psychiatric units in acute care hospitals with the approval process for freestanding psychiatric facilities and expands the licensure abilities of qualified physician assistants and master’s level clinicians working towards licensure. The companion bill, H.4058 from Rep. Marjorie Decker (D-Cambridge) was heard before Financial Services in September.

The committee will also gather testimony on S.1253, An Act to Remove Administrative Barriers to Behavioral Health Services, from Sen. John Keenan (D-Quincy) that would improve access to behavioral health services by expanding the number of behavioral health settings that must be covered without prior authorization. It also mandates that the patient’s treating clinician – not the insurer’s clinician – determines the “medical necessity” of a patient’s care.

Non-Emergency Transportation

On Tuesday, the Joint Committee on Financial Services, chaired by Sen. Paul Feeney (D-Attleboro) and Rep. James Murphy (D-Weymouth), will hear H.1050, An Act to Improve Patient Access to Non-Emergency Medical Transportation, from Rep. Daniel Hunt (D-Boston). The bill addresses emergency medical services (EMS) challenges by ensuring insurance prior authorization for patient transportation is valid for three business days. Providers report that under the current system, many patients’ prior authorizations have already expired by the time they can successfully secure the transportation they need to the next level of care. This expanded authorization period allows for any transport delays; the bill also ensures that EMS providers are adequately reimbursed by MassHealth for non-emergency medical transportation for behavioral health, dialysis, and post-acute care transportation.

MHA Strongly Supports Latest Waiver Amendment

The historic Section 1115 Medicaid Waiver that was approved in September 2022 continues to undergo revisions. Last week, MHA sent a letter to the federal Centers for Medicare and Medicaid Services (CMS) offering its strong support of the latest amendment from the state’s Executive Office of Health & Human Services (EOHHS), which effectively expands access and eligibility for MassHealth enrollees.

For example, the state’s proposed amendment provides 12 months of continuous eligibility for adults and 24 months of continuous eligibility for certain MassHealth members experiencing homelessness. In supporting the measure, MHA’s Vice President of Healthcare Finance and Policy Dan McHale wrote, “Continuous coverage … provides needed stability for low-income residents whose income and other eligibility circumstances may fluctuate and cause them to be ineligible.” McHale also lauded EOHHS for the amendment provision that provides three months of retroactive eligibility for all lower income residents that apply and become eligible for MassHealth.

The Massachusetts waiver agreement includes the Hospital Quality and Equity Initiative Program (HQEIP), which is unique among 1115 Medicaid waivers nationwide. It has been called a template for other states to follow. The HQEIP holds hospitals accountable for an expansive array of measures related to improving health care equity and reducing disparities over five years. The equity program officially began on January 1, 2023, and for the past year Massachusetts acute hospitals have fulfilled numerous deliverables detailed within it. All Massachusetts acute hospitals are participating in the program. And Massachusetts hospitals are contributing $875 million of their own monies over the five-year waiver period to help finance the health equity incentives. The agreement with the federal government ultimately will return $1.8 billion to hospitals that meet their equity goals.

MHA to Convene Maternal Care Advisory Group

As the Healey Administration continues to focus on maternal health initiatives across the commonwealth, MHA announced to its membership last week that it would convene a Maternal Health Advisory Group to help guide policy and best practices relating to birthing equity and health, and perinatal care.

Earlier this fall, Governor Healey charged EOHHS and DPH to complete a review of maternal health services across the commonwealth, including pre- and post-natal care. That directive led to Review of Maternal Health Services, 2023 that was released November 15. Among its findings, the report showed that the rate of severe maternal morbidity (SMM) for all birthing people increased significantly between 2011 and 2020, and that the SMM rate for black, non-Hispanic birthing people was 2.5 times higher that the rate for white, non-Hispanic people.

MassHealth also announced recently that beginning this week it will now cover doula services for pregnant, birthing, and postpartum members. These developments, along with persistent workforce shortages and capacity challenges, make it especially timely for MHA to convene its membership’s experts in the maternal care field under the new advisory group.

New Capacity Tier Designation Issued for Regions of the State

Due to widespread capacity constraints and workforce challenges at hospitals, the state last Thursday immediately escalated three of the state’s Health and Medical Coordinating Coalitions (HMCC) into Tier 2 status.

The state escalated Regions 1, 2, and 3 in the western, central and northeastern parts of the state, respectively. Regions 4 A, B, and C in Boston and Metrowest, and Region 5 in Southeastern Massachusetts and the Cape and Islands, were already in Tiers 2 and 3, respectively.

The tiering system was created during the height of the pandemic and is described in this document. Tier 2 allows hospitals to use their surge bed capacity and to voluntarily reduce elective, non-urgent procedures and services, among other steps to ease their workforce/capacity burdens.

The state reports that acute respiratory diseases resulting in ED visits and admissions are slowly trending upward but are well below the rates from the same period last year. However, the inability to transition patients through the system – from acute care hospitals to post-acute facilities and services – continues to worsen. MHA’s latest (October) throughput report showed that there are 883 patients awaiting discharge from Massachusetts hospitals. As those patients remain in beds awaiting transfer to a skilled nursing facility or other care setting, the number of patients in EDs that are awaiting an inpatient bed grows, compounding the capacity problem. (See story below.)

ED Boarding Harms Clinicians Too

According to the literature, patients who are forced to board in hospital EDs because an inpatient bed is unavailable are more likely to experience medication errors, have longer hospital stays, and may decide to forego care entirely, ultimately leading to worse outcomes. Now a new study in the December 2023 issue of The Joint Commission Journal on Quality and Patient Safety shows that ED boarding has a negative effect on clinicians as well.

“Clinicians reported that boarding highly contributed to the perception of burnout. All groups reported high rates of perceived verbal and/or physical abuse from boarding patients,” according to the study.

MHA continues to track the behavioral health boarding issue on a weekly basis, and is proposing a series of reforms that would mitigate the crisis (see bottom story).

Early Bird Registration for ACHE of MA 2024 Conference

Registration is open for ACHE of Massachusetts’ February 27, 2024, virtual conference entitled “Staying Nimble Through the Healthcare Staffing Crisis.” Post-pandemic challenges, demographic shifts and other broader economic trends continue to create a healthcare staffing shortage of epic proportions. Labor costs are rising and people to fill the necessary roles are shrinking. The 2024 program will be designed to look at these staffing challenges. Among the panelists discussing the topic will be MHA’s V.P. of Clinical Affairs Patricia Noga, R.N. Register here.

Transition: New Leadership at North Adams Regional

Berkshire Health System’s resurrection of North Adams Regional Hospital (NARH) continues apace, with the 25-bed facility expected to begin serving patients in early 2024, pending state and federal approval. Last week, Berkshire named North Adams’ leadership team: Laurie Lamarre will lead the team in the role of Vice President of NARH. She will be joined by Senior Director of Clinical Operations Robert Boebert, R.N.; Operational Manager of the Emergency Room and Medical/Surgical Inpatient Care Jennifer Dowling, R.N.; and Operational Manager for Perioperative Services Lynsey Wilk, R.N.

John LoDico, Editor