INSIDE THE ISSUE

> Mass. on Verge of Joining NLC!
> HPC Cost Trends Hearing
> The Lame Duck Congress
> Insurer: We Need 15 Denials Before We Act
> Caution on Medicare Advantage Plans
> An Innovative Transportation Program
> New Round of MA Repay Loan Forgiveness
> Transition

MONDAY REPORT

Mass. Hospitals, Nurses Celebrate Passage of Nurse Licensure Compact

The commonwealth’s nurses, nursing leaders, and hospitals are celebrating the long-awaited passage of the Nurse Licensure Compact (NLC), which was included in the legislature’s economic development bill approved last Thursday. The bill now awaits Governor Maura Healey’s signature.

In a massive step forward for workforce development, the commonwealth now joins 41 other states and U.S. jurisdictions that have adopted the NLC. The Compact allows qualified nurses to hold one multistate license with the ability to practice in all other “compact states,” eliminating the arduous re-licensure process. With approximately 5,100 vacant R.N. hospital positions throughout Massachusetts, healthcare organizations have long advocated – since as far back as at least 2009 – for the adoption of the NLC as an immediate, commonsense action the commonwealth can take to grow the nursing profession, support frontline caregivers, and expand patient access to care.

“Massachusetts healthcare providers are still struggling with enormous workforce shortages, and the adoption of the NLC provides us with a safe, proven, and transformative solution that can make a difference in sourcing qualified nurses right away,” said Emily Dulong, MHA’s V.P. of government advocacy & public policy. “With this advancement, we’re aligning with 41 other states to support our existing frontline caregivers, improve patients’ access to services, expand the virtual care that alleviates healthcare capacity challenges, and better prepare the commonwealth for times of emergency. We are deeply grateful to the Massachusetts legislature for their leadership in making this milestone possible.”

By adopting the NLC, Massachusetts will:

• allow qualified nurses from across state lines to practice in Massachusetts more easily;
• enable nurses to deliver follow-up telehealth services for patients who return to their home state, including those who receive reproductive and gender-affirming care;
• provide the commonwealth with an important emergency response tool, for cases in which a rapid increase in caregivers is needed; and
• boost the availability of workers in in community-based and post-acute settings.

“This is a pivotal moment for nursing and healthcare delivery in Massachusetts,” said Amanda Stefancyk Oberlies, PhD., R.N., the CEO & chief nursing officer of The Organization of Nurse Leaders – MA, RI, NH, CT, VT. “With the adoption of the NLC, we’re taking a critical step forward in supporting our nurses and addressing workforce shortages that are having a very real impact on wait times and timely patient care. We commend the Massachusetts legislature for recognizing the urgency of this issue and taking action to ease the burdens on our dedicated nurses.”

Among its other healthcare sections, the economic development bill also provides temporary licensure and a pathway to full licensure for foreign-trained physicians. Such flexibility in licensing physicians from other countries was allowed temporarily during the pandemic and proved valuable for meeting the workforce shortage of M.D.s. The legislation also includes $50 million in capital bond funding for nursing facility upgrades to address the needs identified in MHA’s throughputs reports for specialized care.

HPC Hearing Explores Current Problems, Potential Solutions

Another panel featured Dr. Eric Dickson, president and CEO, UMass Memorial Health, and Dr. Anne Klibanski, president and CEO, Mass General Brigham, paired with the leaders of Point32Health and Blue Cross Blue Shield of Massachusetts, Eileen Auen and Sarah Iselin, respectively, who collectively dug down into the challenges of the cost-reduction effort.

MGB’s Klibanski told the HPC that Massachusetts is “near the top of the country in capacity challenges. And we are near the bottom of the country in ambulatory buildout. So, unfortunately, as a state, we are not providing care close to home.”

She said the MGB’s system two academic medical centers – Mass General and Brigham and Women’s – were built to provide the highest-level tertiary and quaternary care. “There are 2,000 patients that desperately want to come into those academic medical centers for treatment they couldn’t get in community hospitals, but we can’t take them anymore,” Klibanski said. “Why? Sixty percent of the care provided in these higher level academic medical centers is secondary care. And that care doesn’t belong at Mass General and the Brigham; it belongs in community hospitals. In fact, a lot of that really belongs in free-standing ambulatory surgical centers that you see all over the country.”

While both Klibanski and Dickson concurred with a major theme of the cost trends hearing – the need to increase primary care availability to keep people healthier and out of hospital EDs – both said hiring more primary care physicians (PCPs) won’t solve the capacity crisis alone, and oftentimes is not financially practical.

“We lose $200,000 every time we hire a PCP,” Dickson said, noting that for each hire, UMass provides office space, technical support, support staff, and salary. Those annual costs are never recovered through the reimbursements that even a PCP with a huge patient panel can bring in annually, he said.

In the final panel of the day, MHA President & CEO Steve Walsh was joined by Michael Curry, president and CEO, Massachusetts League of Community Health Centers; Lora Pellegrini, president and CEO, Massachusetts Association of Health Plans; and Amy Rosenthal, executive director, Health Care For All.

“What’s been talked about over the course of the day is primary care investment, accountable care and value-based care, workforce development, administrative simplification, Medicaid reform, behavioral health parity, and a statewide health plan,” Walsh said when asked about what specific action can be taken to improve the system. “And you know what all of those things have in common? Every single one of them is in Chapter 224” – the sweeping 2012 healthcare reform bill that created the HPC and the cost growth benchmark. “We are focused now on one part of one section of an incredibly complex bill that had the idea of changing and reforming our system – and we spend a lot of time energy and money and regulation talking about a cost-growth benchmark, which worked for a couple of years and now is going the other direction as is the national cost growth average.”

Walsh has consistently argued that directing the healthcare system to focus on the benchmark as an annual target when other cost factors – such as national inflation and the rising cost of workforce, among others – are growing at unsustainable rates is a recipe for disaster.

“You can’t start with the benchmark and work backwards,” Walsh said. “You have to reform and evolve the entire system and then we will be pleasantly surprised that we now have a system that works better for patients, gives us higher quality, and becomes affordable … The low hanging fruit was in front of us 12 years ago and we didn’t do the hard work – and here we are today. So let’s refocus our effort on a bill that was very aspirational at the time and maybe not ready in some of those other areas, and let’s set this cost growth benchmark aside for just a moment and build a better system that makes the benchmark very achievable.”

Will the Lame-Duck Congress Act on Key Health Bills?

The current Congress – the 118th – ends on December 20 as does the most recent Continuing Resolution that funds the government. The new 119th Congress with a Republican-led House and Senate will be sworn in on January 3, 2025.

Between now and December 20, the “lame duck” Congress has before it a series of important healthcare items that will lapse if no action is taken.

For example, during the pandemic, Congress adopted telehealth waivers that expanded where and how such services could be provided. Those flexibilities were subsequently expanded for an additional two years after the end of the public health emergency, but at year’s end they will expire without Congressional action. MHA, hospitals, and other providers are strongly advocating that they be extended either temporarily or permanently.

The same is true for the waivers that permit acute inpatient hospital-at-home programs, which have proven to be a safe way to provide care outside of hospitals and which benefit both patients and facilities facing capacity issues. At the end of the year, the hospital-at-home waiver ends. The American Hospital Association, tMED – The Massachusetts Telemedicine Coalition, and MHA endorse the current Congress passing the Hospital Inpatient Services Modernization Act (H.R. 8260/S. 4350), which would extend the hospital-at-home waiver through 2029.

(In a related item, the Drug Enforcement Administration late on Friday extended telehealth flexibilities for the prescription of controlled medications through December 31, 2025. The DEA said the extension will benefit patients and practitioners that have come to rely on the availability of telemedicine for controlled medication prescriptions, and the additional time will allow DEA and U.S. Health & Human Services more time to promulgate proposed and final regulations on the issue.)

Perhaps the largest healthcare-related measure the lame-duck Congress faces is delaying cuts to Medicaid Disproportionate Share Hospital funding. Such cuts were first included in the Affordable Care Act under the premise that as more people were enrolled in health insurance programs, the hospitals serving a disproportionate share of the uninsured and underinsured would need less funding. But Congress has regularly delayed the DSH cuts recognizing that the funding is critical to safety net providers and Medicaid programs generally.

In Massachusetts, this funding is incorporated into the state’s 1115 waiver and supports supplemental funding for safety net hospitals as well as the Health Safety Net. If Congress does not act, DSH cuts totaling $8 billion will take effect in January 2025, further harming hospitals.

Last year, the Medicaid and CHIP Payment and Access Commission (MACPAC), a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, did an analysis in which it stated, “The Commission is concerned that the magnitude of cuts (54 percent in FY 2024) in DSH allotments under current law may disrupt the financial viability of some safety-net hospitals.” MACPAC estimated the Massachusetts Medicaid DSH allotment would be reduced by $628 million, or -76%, without a change in the law.

Fifteen Insurance Denials Before Approval?

An MHA member hospital earlier this month was confronted with a health insurance company issue that stands head and shoulders above the daily, well-reported delays providers often encounter when attempting to transition patients from one care setting to another.

As often happens, association members call on MHA staff to assist them with a particular issue before an agency, insurer, vendor, or other entity. MHA’s Senior Director of Managed Care Karen Granoff received an e-mail with the subject line: “Looking for assistance w/ payors.” One of the hospital’s patients needed to be transferred to a skilled nursing facility (SNF), and the request was made on a Friday to the large national insurer. It wasn’t until five days later –the following Tuesday – that the insurer finally approved a transfer to the post acute care facility. Unfortunately, such multi-day delays are common with the national insurers.

But what caught Granoff by surprise was the hospital’s second problem with transferring a patient to a SNF – this time through another national insurer. As the hospital case manager wrote to MHA: “We have a SNF bed at a facility that is not contracted with the insurer. We have gotten 9 denials from the insurer-contracted facilities. They are telling us that they need to have 15 denials from their contracted SNFs before they will do an agreement with the SNF that has accepted the patient. This seems a bit ridiculous to me and is wasting time.”

“Yes, 15 denials is ridiculous,” said Granoff, who worked with the hospital and appreciated the assistance from the Mass. Association of Health Plans with identifying a contact at the insurer who could expedite a resolution. “A five-day delay or an insurer’s 15-denial standard before they act create challenging situations for providers and patients. The delays have negative effects on those health plans’ members, who unnecessarily remain in a hospital bed, are bad for hospitals at or near full capacity, and are costly to the entire system.”

Granoff stressed that Massachusetts-based insurance companies are more responsive to provider concerns, but as the large national insurers gain membership in Massachusetts, experience shows that delays and unresponsiveness will undoubtedly increase.

Medicare Advantage Open Enrollment Underway; Do Your Homework

With Medicare Advantage open enrollment underway across the country, and in light of recent concerns over the marketing strategies of the insurers, Massachusetts hospitals are encouraging Medicare eligible residents and their caregivers to do their homework before choosing a plan.

“During this open enrollment period, those eligible for Medicare see a lot of ads, take lots of phone calls, and receive lots of mail about Medicare Advantage plans,” said Adam Delmolino, MHA’s senior director, virtual care & clinical affairs. “Medicare Advantage plans are offered by private companies and can differ from traditional Medicare when it comes to key things like in-network coverage, out-of-pocket costs, and referral policies for specialists. While the plans often offer additional benefits, there is a lot of variation among plan offerings and there are also some restrictions that are not found with traditional Medicare, making it important to do your homework before making a decision.”

The general rule of thumb when dealing with Medicare Advantage is to not rely solely on a broker’s suggestions, but rather to call the plan directly, check its website, or call 1-800-MEDICARE. The main questions to ask are: Will your primary care doctor, or other doctors you see, be in-network? Will your costs (including co-payments) change? Will your prescriptions be covered? Will you need prior authorizations to get the care you need?

MHA has been surveying case managers at its member hospitals and they have indicated that private insurer administrative barriers pose the most significant challenge to discharging patients to skilled nursing facilities, post-acute care hospitals, and home health services. Case managers have cited Medicare Advantage plans and their prior authorization processes as one of the most significant roadblocks to discharges from hospitals.

Additionally, it is also important that Medicare beneficiaries review their Medicare Advantage plan offerings to ensure that the facilities and services that they may use locally (such as physicians, hospitals, nursing homes, post-acute care hospitals, or home health agencies) are in-network for their Medicare Advantage plan. Otherwise, when they use those facilities or services, their insurance may not cover the care.

Those needing assistance in selecting a Medicare Advantage plan, should contact their local SHINE (Serving the Health Insurance Needs of Everyone) program. SHINEs provide free health insurance information, counseling, and assistance to people who are eligible for Medicare as well as to their caregivers. To be connected to a local SHINE counselor and schedule an appointment, call MassOptions, which is a service of the Massachusetts Executive Office of Health & Human Services, at (800) 243-4636 or e-mail SHINE@state.ma.us.

Boston Globe Editorializes on Innovative Transport Program

A Boston Globe editorial last week endorsed an innovative transportation program for behavioral health patients that South Shore Hospital and Lowell General Hospital are both piloting.

The relatively simple, but effective initiative uses retrofitted SUVs to transport behavioral health patients being discharged from a hospital to a psychiatric bed. The “tricked-out” SUVs are staffed by two emergency medical technicians carrying medical equipment. Using a SUV frees up an ambulance, which would otherwise be taken out of service for hours to complete the non-emergent transport.

“Today, insurers generally pay for medically necessary non-emergency transportation in an ambulance,” the editorial notes. “MassHealth will also pay for what is essentially a taxi service, while commercial insurers tend to pay for wheelchair vans. But the behavioral health transportation provided by these hospitals doesn’t fit neatly into these categories. There are no state standards for licensing it and no framework for negotiating insurance coverage. Both hospitals are bearing the costs themselves and setting their own standards for equipment, staffing ratios, and training.”

The editorial proposes “standardizing and regulating these programs” to “ensure they operate under guidelines that protect patient and staff safety. It could also create the potential for insurance reimbursement to make these types of cars financially viable for other hospitals and ambulance companies.”

Growing concern around non-emergency transportation, including the lack of reimbursement for this new tier of transport, has been a central focus of MHA’s EMS Workgroup and several of the association’s priority bills.

Commit to Four Years, Receive Student Loan Repayment Funds

The MassHealth Behavioral Health Student Loan Repayment Program and the MassHealth Primary Care Student Loan Repayment Program are targeted to improve access to behavioral healthcare and primary care services by recruiting and retaining healthcare professionals in community-based settings.

The behavioral health program focuses on professionals serving MassHealth and uninsured patients, offering student loan repayment of up to $300,000 for eligible psychiatrists and nurse practitioners with prescribing privileges, up to $50,000 for Master’s and Doctoral degree-level behavioral health professionals, and up to $30,000 for bachelor’s degree-level behavioral health professionals. Participants must commit to four years of full-time service in a community-based setting, organization, or personal practice with a patient panel of at least 40% MassHealth members and/or uninsured patients.

The primary care program provides up to $100,000 for eligible primary care physicians and $50,000 for advanced practice registered nurses and physician assistants. Participants also must commit for four years.

Applications opened on November 14 and will run through December 12, 2024. Interested candidates can find more information and apply through marepay.org.

Transition

President-elect Donald Trump has nominated Robert F. Kennedy Jr. to be his Secretary of Health and Human Services. Trump wrote on X: “HHS will play a big role in helping ensure that everybody will be protected from harmful chemicals, pollutants, pesticides, pharmaceutical products, and food additives that have contributed to the overwhelming Health Crisis in this Country. Mr. Kennedy will restore these Agencies to the traditions of Gold Standard Scientific Research, and beacons of Transparency, to end the Chronic Disease epidemic, and to Make America Great and Healthy Again!” Kennedy will have to be confirmed by the U.S. Senate.

John LoDico, Editor