INSIDE THE ISSUE

> Prior Auths Reduced
> HPC Hearing
> Apprentices at Cape Cod Healthcare
> LTC Workforce Challenges
> DSH Funding

MONDAY REPORT

BCBSMA Eliminates Prior Authorizations for Home Healthcare

Last Monday, Blue Cross Blue Shield of Massachusetts (BCBSMA) announced it would end prior authorizations for home care services, effective January 1, 2024 for commercial members and January 1, 2025, for Medicare Advantage members.

“This means hospitalized members will not be required to get advance approval before being discharged to continue treatment at home,” the state’s largest health insurance company said in a media release.

MHA and its membership welcomed the BCBSMA change. Also last Monday, MHA released a report showing how burdensome administrative practices, including inflexible insurance company prior authorization requirements, contribute to waste in the healthcare system. The report called for reforms that streamline or eliminate low-value prior authorization requirements that delay access to care, such as the one BCBSMA targeted.

BCBSMA said its policy will reduce an estimated 14,000 prior authorizations for home care services – which include physical therapy, occupational therapy, home health aide and nurse visits, and social worker visits.

“This is exactly the type of administrative simplification that can improve patients’ access to care, ease caregiver burnout, and reduce wasteful costs,” said MHA’s Senior Vice President & General Counsel Mike Sroczynski, in commending the insurer. “In addition to getting patients home quicker with the appropriate care, this change from BCBSMA can also free up the hospital discharge process and help ease capacity constraints being felt across the system. It is a promising step, and we hope it will set an example for other plans to follow. It represents an enormous opportunity for us to come together as a state, reduce the red tape within the system, and create a better experience for patients and caregivers alike.”

HPC Hearing Focuses on Affordability, Equity

The Health Policy Commission (HPC) held a full-day hearing last Wednesday to discuss the state of healthcare delivery and costs in the commonwealth.

Discussion throughout the day focused on two core themes, affordability and equity. Also covered were topics discussed at previous HPC cost trends hearings, such as how high hospital utilization in Massachusetts drives healthcare costs, how communities of color experience persistently worse healthcare outcomes years after such trends were identified, and how healthcare workforce shortages are disrupting the entire care continuum.

Proposed solutions also struck familiar themes. Could the often discussed but unfulfilled plan to have a regional plan for all parts of the healthcare system result in lower costs? Could reducing regulations and improving payments allow for care to be provided in homes as opposed to hospitals, and thereby lower costs? How can the state devote more resources to primary care to keep people healthier and out of hospitals, which in turn would lower costs?

Leaders of the Health Equity Compact, of which MHA is a supporter, spoke on multiple panels about the need for urgency and unity around policies that can make care more accessible, affordable, and culturally competent.

“We have to address the root causes of cost increases,” Governor Maura Healey said at the hearing. “We need to recognize the real financial stress among many of our healthcare providers – from our community hospitals to nursing homes. We need structural solutions to bring greater stability and value across the board for everyone.”

Provider panels also called for cooperation, as did a panel of insurers. “When we come together, we can do amazing things,” said Christine Schuster, R.N., president and CEO of Emerson Health and the chair of MHA’s Board of Trustees. Dr. Kevin Tabb, the president and CEO of Beth Israel Lahey Health, noted that while providers have an important part to play in being part of the solution “the entire state needs to behave as a system.”

Doug Brown, the president of community hospitals and chief administrative officer for UMass Memorial Health, called on the state to adapt as the healthcare system changes. “Government has to change like we do, and you have to start thinking about how you can enable and empower the dramatic changes that are going to happen in healthcare,” Brown said. “We are changing faster than the regulations can keep up, and I urge you to think about innovating yourself.”

There were several topics that received greater prominence throughout the hearing compared to previous years, including the need to ease administrative burdens, and the role that pharmaceutical companies and private equity should play in the state’s cost containment goals.

After the hearing, MHA issued a statement noting that the hearing helped further refine thinking on healthcare challenges and potential solutions at a time when the provider community continues to struggle. “This is a time for Massachusetts to be bold in cutting through red tape, investing in innovative care that improves patient access, and ensuring that every part of the sector is held accountable. We will continue to work closely with the HPC and our partners across healthcare on these challenges,” MHA wrote.

Innovative Apprenticeship Program Celebrates Results

Last week, the program was recognized as a success; 13 graduates completed their training to become nursing assistants and phlebotomists. The initiative, which uses a “learn and earn” model, is supported through the Training and Upgrading Fund. Slots are offered to both internal and external candidates with entry-level experience. Participants are then paired with a mentor and provided with paid, on-the-job training. Most trainees work 24 to 32 hours a week, giving them the time off needed to complete their classwork. Individuals are placed in a permanent role within one of CCH’s facilities upon completing their apprenticeship.

Elected officials, labor leaders, and Secretary of Executive Office of Labor and Workforce Development Lauren Jones were on hand last Thursday to celebrate the collaboration’s success through its first year.

“The apprenticeship program is an innovative model for the healthcare industry,” said Mike Lauf, president and CEO of Cape Cod Healthcare. “The goal of this program is to invest in our community, create meaningful jobs and offer career ladders to give people wonderful opportunities to live the life they want to live here on Cape Cod.”

“At the end of the day, what makes our commonwealth tick? It’s truly the people,” said Jones. “Their talent really helps businesses and institutions like this hospital thrive and our community thrive. We want to make sure we are paving more ways for people to gain opportunity.”

Proposed Regulations Compound Capacity, Workforce Challenges

MHA last week sent a letter to the Centers for Medicare & Medicaid Services (CMS) raising significant concerns with the agency’s proposal to mandate numerical registered nurse staffing standards at long-term care facilities.

MHA noted that the current, well-documented workforce shortages in Massachusetts and across the U.S., and the changing nature of healthcare practice, makes the CMS proposed staffing rules impractical and obsolete. If implemented, MHA said, the mandate would worsen the patient throughput problem.

“The CMS proposed rule also fails to acknowledge and respect the invaluable work of the 9,000 Licensed Practical Nurses working in skilled nursing facilities in Massachusetts,” MHA wrote. “The exclusion of LPNs in the proposed minimum 3.0 hours per resident day requirement is a glaring omission of two-thirds of our state’s direct care workforce and is inconsistent with the Massachusetts definition of roles that count toward the state’s minimum staffing standard.”

MHA noted that skilled nursing facilities in Massachusetts have “an alarmingly stubborn” 21% vacancy rate among direct care staff. Workforce shortages are among the main reasons that 27 nursing facilities across Massachusetts have closed since the start of the pandemic in 2020, MHA added.

“Given that Massachusetts skilled nursing facilities are struggling to meet the staffing needs for the current population of patients awaiting discharge from hospitals, we wish to impress upon CMS that it will be a tremendous – if not impossible – challenge for the commonwealth’s skilled nursing facilities to staff up to meet CMS’s proposed rules,” MHA wrote. “We estimate that it will require 3,000 new skilled nursing facility staff to meet the needs of the proposed rules at the same time that acute care hospitals are competing to recruit these same caregivers to fill more than 5,100 open R.N. positions in our facilities. Additionally, we note that CMS has proposed no supplementary funding to cover the costs of the increased expense of these regulations.”

MHA joined with the Mass. Senior Care Association to call on CMS to forgo the proposed rule and to work with Congress, the administration, and the healthcare community on efforts to build the nursing workforce. MHA sent a similar letter to the state’s Congressional delegation underscoring the proposed rule’s effect on hospital throughput and capacity.

Senate Committee Advances Mental Health & Extenders Act

The U.S. Senate Finance Committee last week unanimously approved the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act of 2023, which would delay pending reductions in Medicaid disproportionate share hospital (DSH) funding, among other actions. Massachusetts Senator Elizabeth Warren (D) is a member of the committee.

The act would delay DSH cuts for two years. Those cuts were enacted as part of the Affordable Care Act as it was thought that increasing health insurance coverage throughout the U.S. would result in less uncompensated care. But coverage levels have not increased as expected and the DSH continue to care for patients for whom they are not receiving adequate payment. In Massachusetts, Medicaid DSH funding is incorporated into the 1115 waiver and supports care provided by safety net providers to Medicaid and uninsured patients.

The act that passed the Finance Committee would, among other items, improve payment rates for specific codes, thereby allowing for the integration of behavioral healthcare into team-based care models. Behavioral health would also be assisted under the act by its focus on streamlining the licensure processes for hospital and health system providers operating across state lines.

For further details of the act, read this section-by-section outline from the Finance Committee.

John LoDico, Editor