INSIDE THE ISSUE

> Dispensing OUD Medications
> 2023 Legislative Session
> It’s Not a 9-to-5 Job
> Medicare Advantage Concerns
> MHA’s Birthing Conference

MONDAY REPORT

Simple Coverage Adjustment for OUD Meds Will Save Lives

In 2018, the legislature passed Chapter 208, which among many other provisions, requires emergency departments to have the capacity to initiate patients on buprenorphine, commonly referred to by one of its brand name formulations – Suboxone. After that law’s passage, MHA put together an expert workgroup to develop guidelines for hospitals to implement medication for opioid use disorder in the ED. That group – along with experts in the field from across the U.S. – determined that it is best practice to discharge the patient from the ED with both nasal naloxone (or Narcan) and buprenorphine in hand.

“But this practice poses operational challenges, because the medications are typically covered under a health plan’s pharmacy benefit, not the medical benefit relevant to the ED,” MHA’s Senior Director of Healthcare Policy Leigh Simons told the Financial Services Committee last week. “Unless the hospital has its own retail pharmacy, there is no way to be reimbursed for discharging patients with these critical medications in hand. This bill from Representative Vargas would expand the settings in which both dispensed naloxone and buprenorphine must be covered to include not only the ED but medical-surgical units, freestanding psychiatric facilities, and substance use disorder facilities. Quite simply, this bill would increase the accessibility of these life-saving medications and help prevent opioid overdose deaths.”

Vargas told the committee that the measures within H.1156, which numerous other states have adopted, could reduce opioid-related overdose deaths by 25 to 50%, according to Massachusetts-based research from the Boston University School of Medicine, Boston University School of Public Health, and Massachusetts Department of Public Health.

Long-Term Care, Pharma in Spotlight as 2023 Formal Session Ends

The Massachusetts Legislature ended formal sessions for 2023 last Thursday and moved the needle on some key issues of interest to the healthcare sector. Measures can still advance until the formal end of the session on January 3, but between now and then any single legislator can halt a bill.

The House responded to long-term care concerns by passing a bill that expands oversight of the skilled nursing sector and seeks to address the capacity challenges that acute care hospitals are under. Of note, the bill creates a two-year pilot program in which insurers must respond within one business day to a prior authorization request – or waive the requirement altogether – for patient transfers to post-acute facilities. The burdens associated with prior authorization have come under increased scrutiny in recent months and are cited as one of the main obstacles for transfer delays among local hospital case managers. The legislation also tasks the Division of Insurance to create a standardized prior authorization form to further streamline the patient transfer process.

The bill also creates a Long-Term Care Workforce and Capital Fund to be administered by the Secretary of the Health and Human Services, in consultation with an advisory committee consisting of various members of the administration along with representatives from the Massachusetts Senior Care Association and SEIU 1199. It establishes workforce training programs and career ladder grants with special emphasis on Certified Nursing Assistants (CNAs), and would allow CNAs to become certified to administer certain medications to residents in long-term care facilities. It also creates a task force to study and propose recommendations to address acute care hospital throughput challenges.

“The task force will examine hospital discharge planning and case management practices; administrative legal and regulatory barriers to discharge; efforts to increase public awareness of healthcare proxies; post-acute care capacity constraints; the effectiveness of interagency coordination; and other items,” according to a legislative fact sheet.

The Senate in its pharmaceutical bill – known as the PACT Act – created new oversight mechanisms on the drug sector to rein in excessive costs. This includes taking steps to protect some, but not all, 340B facilities from onerous pharmaceutical company practices that if allowed would skirt the intent of the federal 340B program. MHA will continue working with policymakers in the weeks ahead to further strengthen the provisions of these bills.

Hospitals to Insurers: Punch the Clock Every Day

It was Saturday, November 11 – Veterans Day – and hospitals across the state were engaged in the round-the-clock choreography of moving patients out of medical surgical floors to post-acute facilities to make room for patients boarding in emergency departments. That critical discharge-transport-and-admission dance often involves health insurance companies as the partner who provides prior authorization approvals for each step of the patient’s journey.

But on Veterans Day – a weekend holiday – the insurance companies weren’t working. And the upcoming Thanksgiving and Christmas holidays? Most insurance companies operating in Massachusetts and nationally are closed on the holidays or have abbreviated hours in the days before and after them.

“We had near record high boarders over the weekend,” one managed care hospital representative wrote to MHA last week. “We need to engage the payers on this to make them available when we need them.” A new MHA report on healthcare administrative waste pinpointed lack of insurer availability as a main pressure point in the healthcare system.

MHA’s Senior Director of Managed Care Karen Granoff says of the persistent issue, “Our hospitals are 24/7, 365 entities with no respite for nights or weekends, and certainly not for holidays. Health insurance plans should be open at least 9-to-5 on weekends and holidays. And if they choose not to do that, then prior authorizations should be waived, and the insurers should be required to pay for whatever care is required on those days. It’s not good for the hospital to have these patients stuck in beds and it’s certainly terrible for patients who need to access the next level of care.”

Medicare Advantage Legislation and Lawsuit

Medicare Advantage plans would have to report how much they pay for patient services and how much patients are responsible for paying out-of-pocket, under legislation introduced last week by Senators Elizabeth Warren (D-Mass.), Catherine Cortez Masto (D-Nev.), Bill Cassidy (R-La.), and Marsha Blackburn (R-Tenn.). In announcing the bill, the senators said insurance records under current reporting requirements can be incomplete or lack key information to combat fraud. The law aims to boost transparency.

Also last week, the large, national UnitedHealthcare Medicare Advantage plan was sued by the families of two deceased individuals. They claim that United’s “illegal deployment of artificial intelligence (AI) in place of real medical professionals” wrongly denied care to elderly patients in Medicare Advantage plans “by overriding their treating physicians’ determinations as to medically necessary care based on an AI model Defendants [United] know has a 90% error rate.” The two families aim to represent others in a class action suit against the insurer.

Birthing Health Equity Conference: Statewide Initiatives and Next Steps

The conference delved deep into the state of maternal health in Massachusetts, including the efforts to reverse morbidity rates for people of color, persons with disability, and persons with behavioral or substance use disorders.

Dr. Hafsatou “Fifi” Diop, the assistant commissioner for health equity at the Department of Public Health (DPH), delivered the keynote address in which she noted the steps DPH is taking to address inequities in care. She highlighted the need for legislation to develop a diverse doula and midwifery workforce, ensure sustainability of maternity programs through improved reimbursement, and enhance education around bias and discrimination. “Doulas are a critical part of the solution to address inequities for black birthing women,” said Maia Raynor, program manager for maternal and child health policy at DPH.

In another panel moderated by Izzy Lopes, MHA’s vice president of health equity, Dr. Renee Boynton-Jarrett, founding director of Boston Medical Center’s Vital Village Network discussed the importance of meaningful community engagement to address the growing gaps in care for black and brown birthing parents and their newborn children. There was special emphasis on the need for coordination between hospital providers and community-based settings, as well as integrating collaborative care models for mental health and wellbeing.

Most recently, DPH released a report reviewing access to maternal healthcare across the commonwealth and identified the 25-action orientated recommendations to equitably address health outcomes.

With these issues in mind, MHA is continuing to support legislation to expand and diversify the maternal health workforce and to require sustainable reimbursement for maternal behavioral healthcare.

John LoDico, Editor