INSIDE THE ISSUE

> Patient Backups
> Prior Authorizations
> Loan Repayments
> Temporary M.D. Licenses
> Delay in Good Faith Enforcement
> Pediatric Care Tool
> Fighting MRSA

MONDAY REPORT

Nearly 1,000 Patients Are Awaiting Transfer Out of Hospitals

Delays in patient discharges to post-acute care settings are a growing challenge for hospitals and post-acute care providers, which include inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities (SNFs), assisted living residences, and home care services, among other settings. An American Hospital Association report issued last week shows that the average length of stay in hospitals has increased by 19% “across the board” in 2022 as compared to 2019.

The most recent MHA survey (November) of just 37 acute care hospitals across the state shows that there were 967 patients awaiting discharge, meaning that under ideal circumstances, in a system without capacity constraints and workforce shortages, the patients would be receiving care at home or in another type of care facility. The non-discharged patients are occupying beds that hospitals need to care for patients that are flooding hospitals due to an uptick in flu cases, conditions resulting from deferred care, and respiratory disorders, among a host of other ailments.

Why Would a Prior Authorization Take One Week?

A persistent problem for patients seeking timely care, and providers attempting to move patients through the care system safely and efficiently, is the prior authorization process from health insurance companies. Waiting for an insurer to determine if a procedure will be covered or is clinically necessary can often take a week or more. And oftentimes, the insurance-paid clinician making the clinical determination is not in the same specialty field as the patient’s physician prescribing the care. According to a 2021 survey from the American Medical Association, 88% of physicians describe the burdens of prior authorization as “high” or “extremely high,” and more than a third reported a serious adverse event for a patient in their care as a result of the system.

Last Tuesday, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to reform the prior authorization process and to improve patient/provider access to health information. The proposal requires more health insurers to implement an electronic prior auth process and identify documentation requirements, establishes new public reporting and transparency around prior authorization metrics, and sets a 72-hour limit for insurers to respond to an “urgent” prior authorization request, but allows a full seven days for “standard” requests. While this is a significant improvement from the current 14 days allowed for Medicare Advantage plans to approve requests, providers say it does not go far enough particularly since CMS’s stated intent is to expedite the prior authorization process. These proposed changes would apply to Medicare Advantage organizations, state Medicaid & CHIP programs, Medicaid managed care, qualified health plans, and federally facilitated exchanges.

MHA is reviewing the voluminous regulation and will make comments to CMS, but the initial reaction among hospital managed care leaders was: what possible benefit would derive from, and what need is there for, a health insurance company taking a week to rule on a prior authorization request from a patient and their physician?

Apply for Loan Repayments of Up to $300K

Applications are now open for the state-funded loan repayment program for behavioral health and primary care workers. There are three separate loan repayment initiatives, offering awards that range between $12,500 and $300,000 per individual depending on their occupation, job setting, academic degree level, and whether the individual works part-time or full-time. The application period began on Monday, December 5, 2022, and will close on Monday, January 30, 2023. The Massachusetts League of Community Health Centers is administering the initiative.

The program is open to a wide group of full-time and part-time healthcare workers, from psychiatrists and nurses, to recovery coaches, case managers, and more. Applicants working with or in underserved communities are prioritized for the grants.

While generally the loan forgiveness program is available for already accrued educational debt, MHA has learned from the Mass League that two categories of applicants are eligible for both current and future qualifying debt: those who work in a psychiatric unit in an acute care hospital or an inpatient psychiatric hospital, and is a mental health technician, a mental health worker, a mental health specialist, a mental health counselor, a certified nursing assistant, a family partner, or a certified peer specialist; or those who work in a substance use provider program and is a community health worker, substance use counselor, a case manager, a recovery specialist, a recovery coach/supervisor, or a licensed practical nurse. Please note that on the application, these roles should select “Associate Degree” if their highest level of education completed is high school or a GED.

This FAQ document from the Mass League contains many details; here is the link to the application page.

State Still Sees Need for Temporary Licenses for M.D.s

An emergency temporary order that has been in effect throughout most of the pandemic stretching back to 2020 has been once again renewed to allow physicians to operate under an “Emergency Temporary License” until the state’s Board of Registration in Medicine (BORIM) grants the doctor a full license.

“The policy presently addresses the ongoing workforce shortages at Massachusetts hospitals which constrains their capacity to admit and treat patients resulted in care delays and reduced access to services,” BORIM wrote, adding that it intends to continue granting temporary licenses at least through June 30, 2023.

Good-Faith Estimate Enforcement Delayed

It’s always been of concern to hospitals – how to abide by, given current technology, a provision of the federal No Surprises Act that requires facilities to share good faith cost estimates with uninsured and self-pay patients prior to any service. Currently, the hospital has to provide an estimated cost for the services it provides. Going forward, the estimates will eventually need to include the expected costs from all providers and facilities involved in the healthcare event. And it will be up to the “convening provider” – in most cases, the hospital – to coordinate with co-providers and co-facilities to create a comprehensive good faith estimate. That will involve creating new technology (that CMS concedes does not yet exist) and new cost sharing business practices between healthcare entities.

Because of the as-yet-unresolved problems, CMS announced last week that is delaying enforcement of the good faith cost estimate rule until the new technologies are developed. Enforcement was scheduled to go into effect January 1, 2023.

PediTrAC Tool Available for Transfer Assistance

A new Pediatric Transfer Availability and Coordination (PediTrAC) tool is now available for hospitals’ use as the strain on pediatric capacity persists. The tool, developed by the Region 1 Disaster Health Response System and Region 1 Administration for Strategic Preparedness and Response, allows pediatric referral centers to report their availability to receive general care and pediatric ICU transfers. It helps hospital clinicians, particularly those in community hospitals and emergency departments, identify providers throughout New England that may be able to accept pediatric patients in need of transfer. It allows referral centers to report their ability to receive general care and pediatric ICU transfers, as well as their transfer phone number. While it is not a real-time dashboard, it is a general aid to identify available capacity, assist community hospitals with finding a receiving hospital, and reduce the number of phone calls needed to successfully place patients. Availability is expected to be updated at least twice daily. Last week, MHA contacted its membership with instructions on how to access the new tool.

Deadline Extended for Enrolling in AHRQ MRSA Program

As MHA informed its membership last month, AHRQ is offering a free, 18-month Safety Program for MRSA Prevention. Last week, AHRQ announced it is extending the deadline for enrolling in the program to January 15, 2023. Also, CME and CEU credits will be available at no charge for physicians, physician assistants, and nursing staff participating in the program. Participants can earn up to 22 credits by attending live webinars, reviewing recorded program webinars, or reviewing slides/scripts for webinars. Full details are here.

John LoDico, Editor