INSIDE THE ISSUE

> State of Healthcare Forum
> Medicare Advantage Criticisms
> Climate Change and Hospitals
> Anti Gun Violence Grant
> Grant to Brigham and Women’s Researcher
> Election Day!
> Transition

MONDAY REPORT

Healthcare Forum Focuses on Reimbursement, Burdens, Cooperation

The Commonwealth of Massachusetts and a series of trusted buyers performed remarkably well over the course of about five weeks this summer and fall, working expeditiously to save six, failing Steward Health Care hospitals. But if anyone thinks that the problems inherent in those hospitals, or in the Massachusetts healthcare system as a whole, have been resolved by Steward leaving the state and the accelerated purchases of their properties, think again.

That was the message last Wednesday at a healthcare forum hosted by State House News Service in Boston. Attended my more than 250 people, the discussion panel featured Dr. Abha Agrawal, president and CEO of Lawrence General Hospital, which bought the two Steward Holy Family Hospitals; John Fernandez, president and CEO of Brown University Health, which bought Steward’s Saint Anne’s and Morton hospitals; Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans; Steve Walsh, MHA’s president and CEO; and Greg Wilmot, president and CEO of NeighborHealth. Chris Lisinski, a reporter for State House News Service moderated the panel.

“The gift that Steward gave us is that we now have a broad recognition that healthcare in this commonwealth is completely unstable,” MHA’s Walsh said.

Persistent problems include a workforce shortage that has resulted in more than 15,000 unfilled positions at Massachusetts hospitals. Those shortages have led to the inability to staff beds, which has resulted in hospitals being at or near full capacity and unable to transition patients to the next level of care. Those problems have, in turn, resulted in large and deepening financial losses to health systems.

Agrawal said that independent community hospitals like hers that are within historically underserved communities are greatly affected by government underpayment. “Medicaid reimbursement rates are not just for providers but are an investment in the community,” she said, adding that reimbursement needs to be viewed through “the equity lens.”

Brown University Health’s Fernandez concurred, saying that while everyone talks about health equity, the health insurance company – Medicaid – that pays for the care provided to less advantaged people consistently underpays for that care. The most recent estimate shows Medicaid paying about 70 cents on the dollar for care in Massachusetts.

“Sixty years ago we developed this system,” MHA’s Walsh said. “We said we are going to underpay in government care and we are going to cross-subsidize it by overpaying in commercial coverage. And what has happened in those 60 years? The number of people on public payer has gone up and the number of people covered by commercial payers has gone down, and we’re shocked that we can’t cross subsidize ourselves out of the problem anymore. It’s an arithmetic problem that we created.”

MAHP’s Pellegrini agreed that the state has more people than ever before on Medicaid, and more people on Medicare due to an aging population. She said that government underpayment does indeed put more pressure on commercial health insurers.

Among the solutions suggested were attacking waste by using existing technology to eliminate the overuse of prior authorizations; reining in pharmacy costs; and ending the sniping between the various components of the system.

“There’s a new crisis every day. And what do the providers do? They treat the people that walk through the door. They take care of people,” MHA’s Walsh said. “And they’re under attack from a whole lot of other people for trying to provide the basic service that we’ve become accustomed to and rely on.”

Many elements of the panel may serve as a preview for next month’s Cost Trends Hearing, where testifiers will include the new hospital operators, healthcare leaders, and insurance executives. The theme of that November 14 event is “From Crisis to Stability: The Path to a More Affordable, Accessible, and Equitable Health Care System”.

Medicare Advantage: “Failing to Deliver”

Massachusetts Rep. Richard Neal (D) joined U.S. Senator Ron Wyden (D-Ore.) and Rep. Frank Pallone, Jr. (D-N.J.) to write a letter to CMS Administrator Chiquita Brooks-LaSure, urging her to use every tool at her disposal to rein in Medicare Advantage plans.

The members of Congress had three key complaints about the Medicare Advantage (MA) plans – complaints that have been well documented and persistent.

First, they noted that MA prior authorization denial rates have “skyrocketed.” The rules CMS has put into place to ensure MA plans mirror the actions of traditional Medicare are apparently being ignored, the legislators wrote, as insurers rely more and more on artificial intelligence to arbitrarily deny prior auth requests. “CMS should conduct greater oversight of plans with high rates of prior authorization and those that are inventing new strategies (i.e., concurrent reviews, pre-payment audits, payment reviews, and payment integrity administrative reviews) to delay or deny care and decrease payments to providers,” the legislators wrote.

Neal, Pallone, and Wyden also complained about MA insurers’ continuing to “bait and switch beneficiaries and taxpayers in their marketing,” especially in creating lists of in-network, mental health providers who later turn out to be just “ghost” providers that the enrollee cannot access.

“Third,” they wrote, “with more than $6 billion in MA plan spending on commissions and marketing, brokers are under pressure to churn through appointments as quickly as possible.” Potential enrollees aren’t presented the full slate of choices open to them, appeals and grievance processes are not explained, and people end up enrolling in plans that are not suitable for them, the legislators wrote. “We call on CMS to use every regulatory, oversight, and enforcement tool at the agency’s disposal to rein in rampant misuse of prior authorization, simplify the experience of choosing a Medicare plan, and put an end to rampant marketing abuses.” (With MA enrollment currently underway, the hard-sell tactics of some insurance brokers is especially concerning.)

In another critique of MA plans – which again hits on a common, persistent criticism of the insurers – Kodiak, the technology company focusing on healthcare finance, released a report claiming that MA plans consistently ignore Medicare’s Two-Midnight rule criteria, and therefore arbitrarily downgrade inpatient claims to observation status, which results in lower reimbursement.

“The data suggests that payors—absent any justifiable reasons—are continuing to apply their own criteria for inpatient admission and dismissing the Two-Midnight Rule for Medicare beneficiaries.,” Kodiak wrote. “While CMS’ MA coverage changes took effect in 2024, the data suggest they are far from complying.”

Climate Was the Topic of Discussion at MHA Last Week

Governor Healey established the Office of Climate Innovation and Resilience on her first day in office and, in doing so, every secretariat now has a climate officer who is responsible for implementing climate-related efforts in their area.

“Addressing climate change in our institutions is the most important thing we can do for the people we serve,” Secretary Walsh told the MHA gathering.

AG: Treating Gun Violence as a Public Health Issue

Attorney General Andrea Campbell has announced a grant opportunity to help public health groups, including hospitals, create and implement gun violence prevention initiatives and interventions. Grant funding will be used to provide training, resources, and programming for communities across the commonwealth, especially those disproportionately affected by gun violence.

In an average year, 257 people die and 648 are wounded by guns in Massachusetts. While Massachusetts has the second-lowest rate of gun violence in the U.S., AG Campbell has made the goal of interrupting and preventing gun-related violence a priority.

According to the AG’s Office, examples of eligible proposals for the Public Health Models for Gun Violence Prevention Grant Program include initiatives that “embed gun violence prevention information in public health settings such as hospitals, schools, and community-based nonprofits; training programs for public health organizations on specific state gun safety-related laws; evidence-based training programs on how mental health, suicide prevention, intimate partner violence and substance use relate to gun violence prevention; and community violence interruption initiatives that incorporate a public health approach such as cognitive behavioral therapy.”

Grant awards will be issued in varying amounts up to $100,000, with an anticipated start date of programs on February 17, 2025. Any questions regarding the grant can be directed to AGOgrants@mass.gov.

Brigham and Women’s Researcher Receives Cancer Moonshot Funding

The Biden Administration’s cancer “moonshot’ program has awarded Hermioni Amonoo, M.D., a psychiatrist at Brigham and Women’s Hospital, $747,000 for her work on easing the anxiety and depression of cancer patients.

Patients receiving bone marrow transplants in the fight against cancer often experience tremendous psychological symptoms, including low levels of positive psychological wellbeing, and diminished quality of life. Amonoo’s work focuses on how to create “scalable psychosocial interventions tailored to the unique needs” of bone marrow transplant survivors. The trial that the moonshot funded through the National Cancer Institute focuses on PATH — a phone-delivered positive psychology intervention.

Amonoo’s award comes through the second cohort of the Cancer Moonshot Scholars program, totaling $6 million. Another Massachusetts-based researcher, Dennis Jones, of Boston University, received $452,000 to study if “angiotensin-receptor blockers can enhance T cell infiltration into breast tumors and if this enhancement, when combined with cancer immunotherapy, can effectively reduce breast cancer progression.”

Vote!

Tomorrow is election day. Polling places are open from 7 a.m. to 8 p.m. If you are in line when the polls close, you will still be able to vote.

In Massachusetts, one of the five ballot questions deals with a healthcare issue. Question 4 would allow persons aged 21 and older to grow, possess, and use certain natural psychedelic substances in certain circumstances.

Of course, the winner of the presidential election will determine the fate of the national healthcare system in the years to come as presidents are able to take executive actions, as well as advance legislative proposal to carry out their plans.

Transition

Justin Precourt, R.N., has been named president of UMass Memorial Medical Center. Precourt has served as interim president of the hospital since July 2023, when the previous president, Dr. Michael Gustafson, resigned to lead the Schwartz Center for Compassionate Healthcare. Precourt has also been serving as CNO; that position will now be held by interim CNO Michelle O’Rourke.

John LoDico, Editor