INSIDE THE ISSUE

> The New BH TRP
> U.S. House Budget Outline
> Medicaid in Massachusetts
> TV Ad
> Increasing HSN Shortfall
> Telemedicine Lowers Costs
> Transition

MONDAY REPORT

New Behavioral Health Platform Could Ease ED Boarding

The Behavioral Health Treatment and Referral Platform (BH TRP) – a real-time view of patients awaiting psych placement that also streamlines admissions – went live last Wednesday.

Individuals in need of inpatient psychiatric hospitalization wait, or “board,” in hospital emergency departments (EDs) for extended periods of time. To facilitate the admission of these patients, the state created the Expedited Psychiatric Inpatient Admission (EPIA) protocol. The BH TRP streamlines clinical workflows related to the EPIA protocol, ultimately supporting more efficient patient placement.

In the first 24 hours of the BH TRP going live more than 1,000 users logged into the system from across the state.

The Massachusetts Executive Office of Health and Human Services (EOHHS), in partnership with PointClickCare, created the technology platform. During the early days of the pandemic, MHA, Massachusetts health plans, and the Massachusetts Association of Behavioral Health Systems (MABHS) joined to investigate how to better automate the EPIA system. As part of a $4 billion spending package involving American Rescue Plan Act (ARPA) funding in 2021, the legislature directed that $5 million go towards establishing an online portal to address the behavioral health ED boarding issue. PointClickCare was awarded the procurement in the summer of 2023 and since that time a cohort of “early adopter” hospitals including EDs and inpatient units (including freestanding psych) started using the platform and were greatly instrumental in helping to refine it.

Among the activities that BH TRP can accomplish are electronically notifying referring facilities, receiving facilities, payers, and state agencies of new patients, and providing real-time visibility into the referral waitlist and patients’ referral status for authorized users at appropriate organizations. Electronic transmission of standardized admissions information is achievable through BH TRP, as is the significant reduction of manual data entry.

All acute hospitals (with an ED and/or an inpatient psych unit) and freestanding inpatient psych facilities in the commonwealth are required to use the BH TRP as specified in the EPIA protocol.

House Narrowly Passes A Budget Resolution Calling for $2 Trillion in Cuts

On February 25, the House of Representatives passed, by a vote of 217-215, its budget resolution, which calls for $2 trillion in federal spending cuts, $4.5 trillion in tax cuts, and a $4 trillion increase in the debt ceiling. The Massachusetts delegation voted nay.

The Senate passed a more modest budget resolution the previous week which does not include tax reforms, which the Senate intends to address in separate legislation.

The House budget resolution calls for $880 billion in spending cuts over the next decade from the Energy and Commerce Committee where reductions are expected to fall heavily on Medicaid, Medicare, and nutrition programs that dominate the committee’s spending jurisdiction. The Senate budget resolution calls for $1 billion in cuts from the Finance Committee, which includes Medicaid and Medicare but has a much broader area of spending jurisdiction. These two very different budget resolutions must be reconciled between the two bodies and those negotiations have begun.

House Speaker Mike Johnson (R-La.) said in an interview with CNN following the vote, “The White House has made a commitment, the president has said over and over and over, ‘We’re not going to touch Social Security, Medicare or Medicaid.’ We’ve made the same commitment. Now, that said, what we are going to do is go into those programs and carve out the fraud, waste, and abuse and find efficiencies.” Johnson added, “You don’t want able-bodied workers on a program that is intended, for example, for single mothers with two small children. That’s what Medicaid is for. Not for 29-year-old males sitting on their couches playing video games. We’re going to find those guys and we’re going to send them back to work.”

The American Hospital Association released a statement prior to the House vote, saying, “We urge you to consider the implications of hinging the budget reconciliation bill’s fate on removing healthcare access for millions of our nation’s patients. These are hardworking families, children, seniors, veterans, and disabled individuals who rely on essential healthcare services.”

Passage of a budget resolution is the first step in the budgetary process called reconciliation and the resolution outlines an agreement on overall spending and revenue targets. Once a reconciled budget resolution has been passed, the committees will begin their review of changes to spending and revenue policies.

Medicaid in Massachusetts: What it Does, Who it Helps

About 72 million people rely on Medicaid nationally. In Massachusetts, where the Medicaid program is known as MassHealth, approximately 2.1 million residents – or about 30% of the commonwealth’s population – have some form of coverage through the program.

According to the most recent Blue Cross Blue Shield of Massachusetts Foundation report, MassHealth: The Basics – Facts and Trends, 37% of all births are paid for by MassHealth, 48% of children in the state are covered by the program, 59% of people with disabilities depend on Medicaid, and 70% of those residing in nursing facilities rely on it.

According to MHA estimates, nearly 20% of Massachusetts hospital gross revenue comes from those enrolled in MassHealth. Public payers – including MassHealth, Medicare, the Health Safety Net – account for 65% of all hospital gross revenue in Massachusetts. A hospital that receives at least 63% of its gross patient service revenue from government payers and free care is considered a High Public Payer Hospital; there are 45 such hospitals in Massachusetts. In short, the Massachusetts and U.S. healthcare system is profoundly dependent on Medicaid and Medicare.

More importantly, the “public payer” programs are, without exaggeration, the difference between life and death for many enrollees. MassHealth coverage also allows many to receive high-quality, essential healthcare without worrying that their care will imperil them financially. It provides more than 2 million people with the resources to support and manage their healthcare needs across the continuum – from primary care, to hospitals, to long-term care, and behavioral health, to the care they receive at home, including prescription drug coverage. The MassHealth program, including through its waivers over the years, is a key reason Massachusetts has achieved near-universal health coverage. And the program in recent years has led efforts in the state, as well as nationally, to improve healthcare outcomes and manage cost growth through increased care coordination, screening, and addressing health-related social needs such as nutrition and housing. MassHealth has also led investments in primary care and behavioral health. Much of this work is accomplished through the program’s historic and innovative Accountable Care Organization initiative, in which hospital health systems play an integral role.

Last week, MHA requested that its membership provide examples of their experiences with MassHealth. What follows are just a few examples that we’ve anonymized:

Reducing Care

• “Maintaining a strong Medicaid program is vital to [our system’s] long-term sustainability and the health of our service area. With a public payer mix of more than 70%, our health system could see severe consequences from any cuts to the Medicaid program. Nationwide changes to how Medicaid is funded at the state level will create funding shortfalls most acutely impacting hospitals that care for low-income, vulnerable communities – including communities across the county we serve. Additionally, any decreases in Medicaid eligibility are likely to raise the rate of uninsured patients, increasing our organization’s burden of free care. Either of these changes could result in difficult decisions negatively affecting our scope of services available to the community, reducing access to overall care.”

Affordable Care

• MassHealth coverage allows people to seek care rather than delay it due to financial considerations. One hospital tells the story of “George” who “was diagnosed with a recurrence of cancer in an emergency visit. Due to his MassHealth coverage, he was connected within days to the oncology team and started rigorous treatment, including chemotherapy, radiation therapy, and multiple surgeries. Recently, he was found to have no residual disease and continues to follow-up with oncology and primary care.”

ED Use and Burnout

• “A significant reduction in Medicaid funding would have severe consequences for both our community and our workforce. Many of our patients, who are low-income and rely on Medicaid for essential healthcare and chronic disease management, would face heightened difficulties in accessing necessary care. These cuts would limit our ability to provide vital services, driving more patients to seek care in Emergency Departments and acute care settings, which would likely result in poorer health outcomes and higher overall healthcare costs. Furthermore, significant funding reductions would exacerbate the already substantial strain on our workforce, leading to increased staff burnout and potentially reduced access to care. Ultimately, such cuts would undermine the health and wellbeing of the very population Medicaid is intended to serve and could have detrimental effects on the broader community’s health.”

Faces of Medicaid Ad Campaign

The Coalition to Strengthen America’s Healthcare has launched a campaign to show the importance of Medicaid coverage.

The ad campaign includes a “Faces of Medicaid” television commercial warning of potentially devastating cuts to the program.

Hobbled Health Safety Net Takes Another Hit

The commonwealth’s Health Safety Net program is in jeopardy. Monetary deficiencies in the program are now exceeding levels not experienced since prior to the state’s historic 2006 healthcare reform law, with the shortfall between available funding and the money expended for care expected to exceed $230 million in FY2025. New estimates show the funding shortfall was $197 million in FY2024. Today, hospitals alone must make up any funding shortfall.

At current deficiency levels, many hospitals will not receive any monies for care provided to low-income uninsured patients even though they pay an assessment into the fund. In late February, the Executive Office of Health and Human Services (EOHHS) reprocessed hospital claims dating back to FY2023 in an effort to identify any discrepancies in the program’s approved reimbursement methodology. As a result of repricing those claims, the amount due to hospitals and community health centers increased for the care they provided to Health Safety Net patients. With little new funding available, EOHHS is forced to reduce the program’s planned 85% minimum reimbursement for hospital services that disproportionate share hospitals provide down to roughly 76%, which will cost the DSHs about $59 million.

For FY2025 and FY2026, MHA is now projecting funding shortfalls to increase and exceed $230 million and $260 million respectively, which will negatively affect all hospitals across the commonwealth, including high-public payer hospitals. Because the shortfalls are so large, DSH hospitals will receive less than what was planned and other hospitals will receive no reimbursement from the fund despite paying into it.

Hospitals and insurers have long paid an equal upfront amount ($165 million annually) to fund the safety net program. The state also provides $15 million. But as the cost of providing care to the uninsured at hospitals and community health centers has increased annually over the past two decades – and as funds have been diverted from the program to fund Medicaid eligibility expansion – the Health Safety Net shortfalls have steadily increased. Hospitals are allocated a share of the shortfall based on their size, with certain caveats.

“The financing fundamentals of this critical program are now broken,” said Dan McHale, MHA’s senior vice president, healthcare finance & policy. “In effect, the increased cost of providing hospital and health center care to the uninsured over the years is being financed solely through the Health Safety Net program’s shortfall allocation, which falls solely on hospitals. Without additional resources, financially challenged hospitals alone will be charged with financing overwhelming funding shortfalls. That will fray this critical safety net program and divert resources away from the care of all patients in a community.”

New Study Shows Cost Benefit of Telemedicine

At this point, telemedicine is almost universally accepted for its ability to bring care to people where they are as opposed to having patients surmount the difficulties of travelling to see their caregivers. But the question that remains is: Does telemedicine lower costs or increase it?

The increased cost argument runs like this: make it easier for people to see a doctor and they will, driving up healthcare spending through overuse.

The lower cost argument is: make it easier for people to get care and they’ll get that care when they need it, rather than putting off visits and worsening their condition, which in turn drives up costs.

Now a new study in JAMA Network helps resolve the debate. The study of 2.3 million Medicare beneficiaries found that those in high telemedicine–adopting health systems vs low telemedicine–adopting systems did have slightly higher total visit rates, but they used low-value tests less frequently, and had modestly lower spending on total visits.

The study, led by researchers at Harvard University, could assist in the ongoing debate in D.C. over the telehealth flexibilities that are due to expire on March 31. Those flexibilities created during the pandemic and extended since then, allow, among other things, Medicare patients to receive telehealth services for non-behavioral/mental health care in their home through March 31, 2025, and allow telehealth services to be provided by all eligible Medicare providers through the end of March. MHA and other healthcare and patient advocacy interests have been advocating for permanent adoption of the flexibilities.

Transition

Dr. Abha Agrawal, the president and CEO of Lawrence General Hospital since January 2024, resigned last Thursday. Agrawal became a member of MHA’s Board of Trustees in January, a position she will now relinquish. Robin Hynds, executive vice president and COO, will serve as acting CEO.

John LoDico, Editor