INSIDE THE ISSUE

> Waiver Advocacy
> Medical Debt Reduced
> House Passes Supp Budget
> MHA Report Shows Health Plan Woes
> Trying to Fund the Safety Net
> Healthy Work Environment: Sturdy Health

MONDAY REPORT

Ensuring that the Best Possible Waiver Emerges

Noting that the state and nation is currently in the midst of “one of the most consequential periods in the history of the Medicaid program,” MHA last week delivered a letter to State Medicaid Director Dr. Ryan Schwarz highlighting measures Massachusetts can take as it seeks the next five-year iteration of the Medicaid waiver from the federal government.

The Section 1115 waiver is the agreement between the Centers for Medicare and Medicaid Services (CMS) and the Executive Office of Health & Human Services (EOHHS) on the structure and financing of the MassHealth program for five years beginning on January 1, 2028. The final state proposal Massachusetts sends to CMS this year will be the subject of negotiations between the state and CMS throughout 2027.

The hospital community has viewed the upcoming waiver as a “critical opportunity” to mitigate the upcoming financial disruptions that threaten providers’ viability and care services.

Among the major “asks” from MHA was a request that the commonwealth prioritize the expansion of federal financing authority in the Safety Net Care Pool (SNCP) to support increased Safety Net Provider Payments, with flexibility to design hospital eligibility, payments, and conditions of participation. Increased funding would also support the growing uncompensated care and Health Safety Net pressures.

In response to MassHealth’s proposal for a new hospital incentive program, MHA called on the state to create an Access & Innovation for Massachusetts Hospitals (AIM-H) Incentive program that supports both care delivery innovation and access to essential services. MHA also strongly stressed the importance of protecting the current 340B program, writing, “MHA remains fundamentally opposed to proposals that would require hospitals to exchange existing 340B resources for Medicaid supplemental payments.”

“MHA encourages EOHHS to be bold in its waiver requests and evaluate each component of the proposal through a common lens: whether it strengthens or weakens the commonwealth’s overall ability to support hospitals and health systems at a time of severe strain as they deliver care to MassHealth beneficiaries and a rising population of uninsured patients,” said MHA’s Interim President & CEO Mike Sroczynski.

70,000 Patients Will Have their Medical Debt Erased This Week

The latest phase in the effort to erase the medical debt of many individuals in Eastern Massachusetts continues this week, when nearly 70,000 residents will receive more than $38 million in direct medical debt relief through a partnership created by the Atrius Health Equity Foundation.

Under the plan announced last Thursday, low- and moderate-income residents in Eastern Massachusetts will receive medical debt erasure between $5 and $86,000. The patients will receive Undue Medical Debt branded envelopes in the mail this week notifying them that some or all of their medical debt is being erased. The debt relief was made possible by a partnership between the Atrius Foundation, the national nonprofit Undue Medical Debt, and a blend of health providers and secondary market partners in Massachusetts. Since 2024 the partnership has erased more than $293 million in medical debt in Massachusetts.

According to a press release from the foundation, the 69,527 low- and middle-income residents who will receive debt reduction includes 346 residents of Barnstable County (receiving a total of $178,000), 664 residents of Bristol County ($301,000), 34,369 residents of Essex County ($18.6 million), 28,756 residents of Middlesex County ($16.7 million), 1,665 residents of Norfolk County ($731,000), 1,200 residents of Plymouth County ($516,000), and 2,523 residents of Suffolk County ($1.07 million).

“Medical debt not only impacts families’ long-term financial future, but also makes people reluctant to seek care,” said Dr. Ann Hwang, president of the Atrius Health Equity Foundation. “Our hope is that the patients and families across Eastern Massachusetts aided by this debt relief can move forward without this burden.”

“We are proud to see how local providers continue to step up and relieve the burdens on patients, especially as the healthcare environment becomes more challenging for all of us,” said Mike Sroczynski, interim President and CEO of the Massachusetts Health & Hospital Association, which serves as a partner in the debt relief efforts. “It has been special to see how this collaboration has grown over the course of just six months. It has touched lives in ways we will never know.”

Undue Medical Debt works with partners like hospitals, health systems, and physicians’ groups to purchase past-due medical debts in large portfolios for pennies on the dollar and then erases the debt belonging to those least able to pay. There is no application process for debt relief, and it cannot be requested. Patients are automatically selected if they meet certain income criteria and their medical debt is available for acquisition through a partnership with a provider, such as a hospital or collection agency. Patients receiving the letters do not need to take any action.

House Advances Supplemental Budget with 340B Protections

The Massachusetts House passed its version of Governor Maura Healey’s supplemental budget last Wednesday, devoting $2.35 billion to a wide variety of programs, including $56 million to increase nursing home reimbursement rates, $1.8 billion to settle end-of-the-year MassHealth funding, and $2 million to fund DPH’s Welcome Family home visiting program.

Of importance to hospitals, the House passed an amendment, based on a version filed by Rep. Kate Lipper-Garabedian (D-Melrose), that restricts changes to pharmacy reimbursement and coverage in the MassHealth program – specifically, changes that that would reduce the benefits that safety net hospitals rely on through the federal 340B Drug Pricing Program. The House directive prohibits material changes until an alternative 340B hospital access stabilization payment program is achieved in the next iteration of the state’s 1115 waiver. The adopted language also directs the Executive Office of Health and Human Services (EOHHS) to provide extensive analysis on proposed pharmacy changes, including projected net state savings, the estimated financial and operational effect on community health centers and hospitals, and its plans to mitigate that financial impact on providers. MHA has opposed the controversial MassHealth pharmacy carve-out proposal and the alternative 340B supplemental financing arrangement included in the draft waiver proposal.

“The hospital community is grateful to the House of Representatives for standing up for hospitals and requiring MassHealth to pause additional policy changes that restrict hospital access to the federal 340B drug program,” said MHA’s Executive Vice President Lauren Peters. “We greatly appreciate Speaker Ron Mariano, House Ways and Means Chair Aaron Michlewitz, Representative Kate Lipper-Garabedian, and the entire House for acting to protect safety net hospitals and preserving access to this critical program that supports care provided to MassHealth patients.”

The Senate is expected to take up its version of the supplemental budget in the coming weeks.

Local Health Plans Felt the Pain Along with Hospitals in 2025

The MHA’s members-only Annual Health Plan Performance Report, which analyzes the financial position and membership of health plans in Massachusetts, reveals that nearly all Massachusetts-based health insurance companies experienced financial losses in 2025.

Like hospitals, the plans faced soaring pharmaceutical costs, particularly for GLP-1 weight loss medications. Also like hospitals, health plans are affected by the provisions in the One Big Beautiful Bill and other federal changes that have resulted in insurance coverage losses, and Medicaid financing cuts, among other headwinds affecting the healthcare sector.

With the exception of the national plans, every local health plan included in the MHA report had a negative operating margin in 2025, ranging from -0.9% for Health New England to -5.4% for Harvard Pilgrim Health Care. In 2025, aggregate health plan net worth surplus decreased from $6.2 billion to $5.6 billion. Blue Cross Blue Shield of Massachusetts (BCBSMA) plus HMO Blue continue to hold the maximum share (56%) of total health surplus in the commonwealth, although its share fell by four percentage points from the prior year.

BCBSMA and HMO Blue also continue to dominate with 40% of the commercial market followed by Point32Health with 20% of the commercial market. Tufts, BCBSMA, and UnitedHealthcare together represent 75% of the Medicare Advantage market.

To address these losses, some insurers took aggressive measures throughout 2025 that culminated in sweeping coverage restrictions implemented for the 2026 plan year. For example, BCBSMA and Point32Health ended automatic coverage for GLP-1 drugs prescribed purely for obesity. The plans, like hospitals, have laid off hundreds of employees or offered buyouts. And many carriers requested and received substantial double-digit premium increases for individual and small business plans to help cover the rising cost of medical care.

National health plans reported positive operating margins for their nationwide business: Cigna 8.8%, Elevance 3.6%, United Healthcare 2.7%, and CVS/Aetna 1.7%.

Hospitals Open to Unique Way of Funding Health Safety Net

It’s certainly an unusual way to raise revenue, but if it can help fund the seriously depleted Health Safety Net fund then it’s certainly worth pursuing. That’s the thinking of a wide swath of the healthcare community – as well as Massachusetts House Speaker Ronald Mariano (D-Quincy) – should state policymakers approve “historic horse racing.”

An amendment from Rep. Adrian Madaro (D-East Boston) to authorize historical horse racing in the state was included in the economic development bill now in conference committee. Such betting allows players to wager on electronic replays of past horse races using a pari-mutuel betting system. All identifying parts of the races (names of horses, jockeys, courses, etc.) are stripped out but other performance data and odds are kept in to allow people to bet. Madaro’s amendment would dedicate a portion of the “take” to the Health Safety Net.

As has been definitively documented by numerous sources, the Health Safety Net, which reimburses uninsured care that patients receive at hospitals and community health centers, has been severely underfunded almost since its inception in 2006. Its shortfalls currently have been averaging about $300 million per year prior to ad hoc legislative funding relief; hospitals alone must absorb those shortfalls.

Numerous sources also note that the One Big Beautiful Bill will force close to 300,000 Massachusetts residents out of their current health insurance coverage, thereby driving up demand on the Health Safety Net, which is projected to increase its funding shortfall by $600 million annually because of the newly uninsured. Hence, the embrace of the funding concept should historical horse racing move forward.

In a State House News Service article, Speaker Mariano noted the 300,000 that will lose health coverage, adding, “That means these people will have no healthcare, and where are they going to go? They’re going to walk in the safety net hospital emergency rooms. We’ll be back to where we were in 2006.” Noting his involvement with the historic universal coverage law that also created the Health Safety Net, Mariano said, “I was on the front lines of that; we were forced into some major, significant changes in healthcare because we couldn’t afford to pay the hospitals to stay open. So we’re heading towards a repeat of that performance.”

Part 2:
The Massachusetts Healthy Work Environment (HWE) Academy

Last week’s Monday Report featured Holyoke Medical Center’s “Scale It. Nail It.” initiative to improve patient care and prevent nurse burnout by aligning assignments with real-time patient acuity rather than just traditional census.

The hospital’s nurse-devised initiative was created through the statewide Healthy Work Environment (HWE) Academy – an initiative born out of MHA’s Workforce Leadership Task Force that empowers frontline nursing teams to lead sustainable improvements in workplace culture, nurse retention, and patient outcomes.

This week we focus on Sturdy Health’s “Cleared for Takeoff” initiative that improved workflow and communications between departments (see below).

During the HWE Academy’s intensive year-long process, each participating hospital identifies a unit nursing team to address a specific on-the-job challenge that is hindering their ability to work at their best. Using a series of in-person and virtual workshops, the teams design, implement, and sustain projects to address that challenge. They have access to educational sessions and expert mentoring throughout their journey and are offered “train the trainer” resources to help scale their projects to other units in their organizations.

The initial cohort of 10 hospitals, coordinated through MHA, worked with the American Association of Critical-Care Nurses (AACN) and participated in its Clinical Scene Investigator (CSI) Academy’s Nursing Workforce Solutions program. Johnson & Johnson provided financial support at no cost to the cohort. The second cohort of 10 hospitals is now underway. Due to the tremendous results from the first cohort, MHA is underwriting the costs of cohort 2.

Cohort 1 consisted of Baystate Wing Hospital, Beth Israel Deaconess Medical Center, Berkshire Medical Center, Boston Medical Center, Cape Cod Healthcare, Holyoke Medical Center, Newton-Wellesley Hospital, Tufts Medical Center, Spaulding Rehabilitation Hospital Boston, and Sturdy Health. Cohort 2 includes Beth Israel Deaconess Medical Center, Beverly Hospital, Cambridge Health Alliance, Cooley Dickenson Hospital, Emerson Health, Fairview Hospital, Lowell General Hospital, New England Baptist Hospital, UMass Memorial Health – Milford Regional Medical Center, and UMass Memorial Medical Center. AACN is currently accepting applications for another cohort of hospitals to go through the CSI Academy’s Nursing Workforce Solutions program, funded again by Johnson & Johnson, and MHA has connected with all Massachusetts chief nursing officers to encourage them to apply.

Sturdy Memorial Hospital’s “Cleared for Takeoff:
Interdisciplinary Collaboration Is the Runway to Better Patient Care”

At Sturdy Memorial Hospital emergency department (ED), part of the Sturdy Health system, patients requiring diagnostic imaging depend on safe, efficient, and timely transportation to support rapid diagnosis, treatment decisions, and disposition planning. While the existing process successfully supported patient care, opportunities were identified to further strengthen communication, streamline workflows, and improve the overall experience for both patients and staff.

Prior to the Healthy Work Environment (HWE) project, communication between the ED and Imaging departments relied on several intermediaries, including unit coordinators, often delaying the exchange of information between clinical teams. Imaging also lacked a direct method of communicating with nursing staff. These communication barriers contributed to frustration between the departments and made coordination more challenging. In addition, because the ED does not have a dedicated transport team, transportation to and from Imaging became a shared responsibility among Imaging staff, nurses, and ED technicians.

Ultimately, the process involved multiple team members, communication points, and handoffs. To address these complexities, the Sturdy RN team implemented changes designed to streamline communication and reduce delays in care.

During the project kickoff, the HWE team implemented a new transportation workflow that established more direct communication between imaging and nursing staff. They educated staff on how to update their phone extensions at the start of each shift in the electronic charting system and created tracking board access for all imaging departments. The tracking board allows imaging to identify the nurse caring for each patient and to view their phone extension in real time. The team also eliminated the paper-based “ticket to ride” process, reducing administrative burden, supporting patient privacy, and creating a more streamlined electronic workflow.

Further, the plan established microblog access for all nurses so that another form of direct communication between disciplines is available. Nurses are regularly using microblog access to communicate with hospitalists regarding admitted patients, which has been especially crucial during busy boarding season.

This project demonstrated how relatively simple workflow redesigns and improved communication pathways can have a meaningful impact on patient care and staff experience. By reducing unnecessary handoffs, creating direct lines of communication, and leveraging existing technology more effectively, Sturdy Memorial Hospital strengthened collaboration between the ED and Imaging departments while supporting timely, high-quality patient care.

John LoDico, Editor