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MONDAY REPORT

Patient Transfers: A Persistent Problem

The latest MHA survey from November 2023 shows 750 patients from 42 reporting hospitals were awaiting discharge from hospitals. These are patients who have received all of the care they require from the acute care hospital but now need further specialized care from a skilled nursing or rehabilitation facility, or through a home health agency. Of the 481 patients in November awaiting discharge to a skilled nursing facility (SNF), 42% of them, or 202 patients, have been waiting for 30 days or more; 26 patients awaiting discharge to an inpatient rehabilitation facility or long-term acute care hospital were also waiting 30 days or more, as were 33 home health patients.

Based on data trends, the backups are expected to worsen in the coming months. The December 2022 to March 2023 winter totals, taken from a smaller sample of hospitals during the height of flu/COVID/RSV season, showed the numbers of patients stuck in acute hospitals beds totaling more than 1,000 per month. A full year of MHA reporting available here shows an average of 826 patients per month awaiting transfer from a range of 33-to-43 reporting hospitals.

Hospitals and post acute providers have taken action throughout the year to help resolve the issue. Hospitals and SNFs are coordinating “continuous admissions” over the weekends – a process made difficult because insurance companies, especially Medicare Advantage plans, often are only available 9-5, Monday-to-Friday to give the necessary authorizations for the transfers. Workforce shortages at the post-acutes are also a great problem that the healthcare system hopes to further address in 2024.

MHA Report Shows Insurers’ Enrollment, Finance Trends

MHA last week released to its membership its Semi-Annual Health Plan Performance Report that analyzes the financial position of health insurance companies operating in Massachusetts from January 2019 through June 2023, with a focus on the first half of 2023.

Because of the MassHealth re-procurement process, membership shifts were particularly notable in the first half of 2023 from insurers that contract with Medicaid. Tufts Public lost 200,000 members in Medicaid due to its severed contracts with two of its four accountable care organizations (ACOs); WellSense gained nearly 300,000 members, almost all in its Medicaid business, because of new contracts with four additional ACOs.

Financial results for the first half of 2023 were mixed, with Health New England, Fallon, Harvard Pilgrim Health Care, MGB Health Plan, and Tufts Health Plan showing net losses and the remainder showing positive profit margins. The highest profit margin was 4.6% for United Healthcare.

Sen. Warren Seeks More Medicare Advantage Transparency

Senator Elizabeth Warren (D-Mass.) joined Senators from both sides of the aisle in asking the Centers for Medicare and Medicaid Services (CMS) to gather and publish more data from Medicare Advantage plans on how the insurers make prior authorization decisions.

In a letter to CMS Administrator Chiquita Brooks-LaSure, the senators cited data that shows Medicare Advantage (MA) plans often deny prior authorizations and payments that meet Medicare coverage rules, “meaning the MA plan delayed or denied seniors access to services that would have likely been approved under traditional Medicare.” MA plans also have enjoyed billions in overpayments, according to research cited in the letter, signed by Warren, Senators Bill Cassidy, M.D. (R-La.), Catherine Cortez Masto (D-Nev.), and Marsha Blackburn (R-Tenn.).

“These findings raise important questions about ensuring the integrity and fiscal sustainability of the Medicare Advantage program,” they wrote. “Without publicly available plan-level data on prior authorization requests by type of service, timeliness of determinations and reasons for denials; claims and payment requests denied after a service has been provided; beneficiary out-of-pocket spending; and disenrollment patterns, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms.” The letter goes on to request that CMS collect and publish specific data points.

In Massachusetts, providers cite prior authorization delays and decisions, among other insurance administrative burdens, as the most common reason for transfer delays (see above story). A recent MHA report, BETTER CARE, LOWER COSTS: How Massachusetts Can Lead on Sensible Insurance Reform, showed how hospitals and health systems face a growing volume of prior authorization requirements and instances when they are unable to resolve claims disputes with an insurance company because of administrative roadblocks. Blue Cross Blue Shield of Massachusetts recently announced it is removing prior authorization requirements for home care services, starting January 1, 2024.

Merry Christmas, Happy Holidays

Monday Report is taking a holiday break and will return January 8. MHA wishes you and yours a healthy and happy new year.

John LoDico, Editor