INSIDE THE ISSUE

> “Stuck” Kids
> Healey’s Proposed FY24 Budget
> House’s Supplemental Budget
> FOCUS ON WORKFORCE: Cape Cod Healthcare
> 55% of M.D.s Suffer Burnout
> DEA on Life Post-PHE
> CMS on Post-PHE World
> Transitions at LGH, Lahey

MONDAY REPORT

Kids Stuck in Hospitals with No Place to Go

A new survey from MHA and the Massachusetts Association for Behavioral Health Systems (MABHS) shows that throughout the year at Massachusetts hospitals, dozens of “state-agency-involved” children are ready to be discharged but are “stuck” in the hospitals because they cannot access the next level of care they require.

State-agency-involved patients are those whose case management requires the participation of a state agency and/or access to state agency services, such as those provided by the Department of Children and Families (DCF), Department of Mental Health, Department of Developmental Services, and Department of Youth Services.

The most recent survey results, from December 2022, of 29 hospitals and five freestanding psychiatric facilities showed there were 69 such stuck patients. Patients who are typically referred to as stuck are those facing barriers in transferring out of a hospital’s inpatient or emergency department setting. That is, these pediatric patients need care provided in the community, such as residential settings or group homes. Such patients typically present with conditions that are medically or behaviorally complex. Pediatric patients with diabetes as one of their conditions pose a particular challenge, according to the MHA survey. Of the 69 stuck patients in December, 57 were involved with DCF. In addition to the 69 stuck patients who were involved with state agencies, there were an additional 50 stuck pediatric patients who were awaiting residential education through local education agencies.

These agency-involved patients awaiting discharge to another setting are distinct from pediatric patients who are “boarding” in hospitals as they await an inpatient bed. MHA’s survey of boarding pediatric patients (see story at bottom of page) shows there are regularly from 90 to 150 children waiting for an inpatient bed.

“As MHA continues its work to highlight the causes of capacity and access challenges now being seen around the state, this was a critical population to take into account,” said Leigh Simons Youmans, MHA’s senior director of Healthcare Policy. “We hope this new data can help steer the long-term solutions that providers, state leaders, and our partners throughout the mental health space are now exploring.”

Survey comments on the challenges to discharging stuck children emphasized the “lack of appropriate placements for children with both behavioral and medical needs” and “not enough beds” for children and families seeking state agency services.

Recommendations made in the report include provisions of MHA-supported legislation, bill, An Act to Ensure Access to Behavioral Health Services for Children Involved with State Agencies, HD3059 and SD965, filed by Representative Marjorie Decker (D-Cambridge) and Senator Brendan Crighton (D-Lynn), respectively. These provisions include centralizing the DCF process to escalate cases and conducting a study to determine system needs, including alternative models for children with complex and/or chronic medical and psychiatric needs, among other provisions that build off of legislation passed last year, The Mental Health ABC Act. Additionally, this issue would be aided through Governor Healey’s budget proposal to increase DCF’s funding by $52.5 million to support congregate care providers to increase capacity to the levels needed to serve children involved with DCF.

Placement challenges that delay the discharge of patients from hospitals exacerbate the pediatric behavioral health crisis across the continuum. The survey showed that state-agency involved pediatric patients were disproportionately stuck in an ED (49%) or an inpatient psychiatric unit (37%). The longest wait times for stuck pediatric patients were between 61 and 100 days, with more than half of patients waiting over 10 days. While these children wait to be discharged, they occupy inpatient psychiatric beds that other children are waiting for as they board in EDs and on medical/surgical floors.

Governor Healey’s First Proposed State Budget

Last Wednesday, Governor Maura Healey released her administration’s Fiscal Year 2024 state budget, or H.1. The $55.5 billion spending bill represents a 4.1% increase over FY2023 levels. Governor Healey described the proposed budget as a “down payment” on supporting and preparing students for their careers, addressing the implications of climate change, and making the commonwealth more affordable for residents. It complements the tax relief and reform proposal that the governor unveiled earlier in the week, which would implement a new credit for parents and caregivers of children younger than 13, disabled adults, and seniors.

Of particular importance, H.1 includes $28.61 billion for the Executive Office of Health and Human Services (EOHHS), which, when excluding supplemental payments to hospitals, is a 3% ($905.2 million) increase from FY2023. H.1 makes significant investments in the workforce by annualizing FY2023 Chapter 257 human service employee rate investments, increasing the salary benchmarking for rates that will be set in FY2024 to the 53rd percentile of the Bureau of Labor Statistics, funding an outcome-based incentive program at the Department of Developmental Services to expand provider and residential capacity, and investing to stabilize the congregate care network at the Department of Children and Families.

Additionally, the budget makes several important investments relative to social determinants of health, including increased funding to the Housing Development Incentive Program to unlock more market-rate housing in the state’s Gateway Cities, and nearly a billion in funding for the proposed Executive Office of Housing and Livable Communities secretariat – a 12% increase over the FY2023 Department of Housing and Community Development budget.

H.1 also addresses the behavioral health crisis by expanding community-based services for children and adults across the continuum of care.

While the proposed FY2024 MassHealth budget will be a slight increase over the FY2023 appropriation, it will actually represent a $1.9 billion reduction relative to estimated FY2023 spending according to the administration – a net savings to the state of $254 million taking into account changes in federal revenues. The reason for the decrease is the anticipated reduction in the caseload due to upcoming MassHealth redeterminations. The massive “redetermination” process – that is, validating MassHealth member eligibility for the program – is expected to reduce MassHealth enrollment by 300,000 over time, according to EOHHS. That redetermination process will begin in April and will extend for one year. Efforts are now underway to make MassHealth enrollees aware of the upcoming renewals and to encourage people to update their contact information to ensure they receive notice to reapply for coverage. Massachusetts hospitals will play a major role in helping MassHealth members maintain their coverage or find new health insurance offerings, including through the Health Connector.

House Passes Supp; Senate Action Expected This Week

The Massachusetts House last week passed unanimously a supplemental spending bill, H.57, An Act making appropriations for the Fiscal Year 2023 to provide for supplementing certain existing appropriations and for certain other activities and projects. The Senate is expected to act on the bill this week.

The bill contains many of the elements of the supplemental spending bill Governor Maura Healey filed last month. The measures of interest to the healthcare community – all of which MHA supported – include $130 million to keep expanded Supplemental Nutrition Assistance Program assistance (SNAP benefits) in place for extra months; those benefits ended last week with the phase out of a federal pandemic-era assistance program. More than 630,000 Massachusetts families would be affected without the expanded SNAP benefits in H.57. The “supp” also contains $65 million for the universal school meals program and $9.3 million for the Massachusetts Broadband Incentive Fund. Also, $86 million is devoted to the emergency shelter system and $68 million for early education and care workforce stabilization grants.

FOCUS ON WORKFORCE:
Cape Cod Healthcare’s Apprentice Program for CNAs, Phlebotomists

The program is open to internal candidates to assist current workers shift or grow their careers in healthcare but are also open to external candidates as well. The apprenticeships were created in collaboration with the SEIU union and are funded through CCH’s Training and Upgrading Fund.

Once accepted, candidates are provided a mentor and receive paid on-the-job training. CCH also pays for the education part of the program. The weekly hours are limited to 24 to 32 to allow the worker time to pursue the classroom component.

The first cohort saw four applicants in the phlebotomy program and 12 CNA candidates, and CCH is looking to expand the apprentice program to other positions, such as medical coding.

Learn more about Cape Cod Healthcare’s program, as well as about other workforce initiatives throughout the state, by visiting MHA’s Workforce Toolkit. Do you have a workforce program that you would like featured in the toolkit? Contact MHA’s Kim Stevenson at kstevenson@mhalink.org.

MMS Physician Survey: Burned Out & Leaving Their Practice

The Massachusetts Medical Society (MMS) released a survey last Thursday showing that 55% of respondents experienced symptoms that reached the threshold of “burnout” and 27% of respondents indicated they expected to leave the field of medicine within two years.

The report findings note that more attention is needed on the occupational well-being of particular groups, especially younger physicians, female physicians, physicians of color, and physicians from underrepresented populations. Almost a quarter of all respondents (regardless of gender/race ethnicity) reported that gender and racial inequities and/or structural sexism/racism cause workplace stress. Among respondents who identified as Black/African American, 86% cited racial inequities and/or structural racism as their number one work stressor. Among the 22 respondents who identified as Hispanic, 41% cited racial inequities and/or structural racism as a work stressor.

The top work stressors (which varied by gender, race, and ethnicity) were: increased documentation requirements not always related to clinical care (80.9%); lack of support staff for non-medical tasks (64.2%); and prior authorization requirements (58.2%).

MMS and MHA in 2018 created a first-of-its-kind Joint Task Force on Physician Burnout, which convened meetings and forums, and published a series of white papers, including the well-received A Crisis in Healthcare: A Call to Action on Physician Burnout.

MMS recommends a series of changes to reduce stress, including improving electronic health record documentation and processes; addressing workforce/staffing issues; addressing excessive administrative burdens, such as the insurance industry’s insistence on prior authorizations; aligning and reducing the host of quality measures that vary among payers; and confronting the issue of racism and sexism through a series of targeted actions.

DEA: Controlled Substance Prescribing After COVID-19 PHE Ends

In late February, the Drug Enforcement Agency (DEA), in conjunction with the Department of Justice (DOJ) and the Department of Health and Human Services (HHS), announced a set of proposed rules outlining the process for prescribing controlled substances via telemedicine after the expiration of the COVID-19 public health emergency (PHE).

A prescription for a controlled substance via telemedicine generally requires an in-person medical evaluation; however, the Controlled Substances Act contains certain exceptions to this requirement, including when the HHS Secretary has declared a PHE. Throughout the PHE, DEA-registered practitioners have been permitted to issue prescriptions for all schedule II-V controlled substances to patients, including those with whom they have not conducted an in-person medical evaluation. Under the proposed rule, the PHE-era polices would be scaled back, but practitioners would be allowed to prescribe a 30-day supply of Schedule III-V non-narcotic controlled medications and a 30-day supply of buprenorphine for the treatment of opioid use disorder (OUD) for individuals who have never undergone an in-person evaluation from a medical practitioner.

MHA is concerned about limiting access to OUD care at a time where opioid use and increased overdoses have led to the need for continuing the federal opioid public health emergency. In particular, MHA and its members are concerned that the proposed DEA rules would time limit virtual prescribing of controlled substances and buprenorphine to 30-day supplies before a medical exam is required; impose increased recordkeeping requirements; and impose additional limitations on virtual prescribing of controlled substances without a prior in-person exam. As the healthcare system continues to face increased capacity, burnout, and workforce shortages, MHA is urging, at a minimum, that DEA establish a registered telemedicine program to ensure patients can continue to access the critical services that have been available virtually throughout the COVID-19 pandemic. MHA plans to submit comment to the DEA regarding the proposed rules.

What’s Staying and What’s Going After the PHE Ends

Your insurance company should still cover COVID-19 vaccines without cost sharing after the Public Health Emergency (PHE) ends in May, although insurers aren’t on the hook for covering over-the-counter and laboratory-based COVID-19 testing post-PHE, according to a new “What Do I Need to Know” document from the Centers for Medicare and Medicaid Services (CMS).

During the pandemic, the federal government instituted a host of waivers from healthcare regulations that allowed providers numerous flexibilities to treat the influx of patients quickly. Clinicians were able to get licensed quicker than usual and the tasks they were allowed to perform – that is, their “scope of practice” – were expanded. Hospitals were allowed to use alternative spaces for care and to use telehealth more creatively. Now, with the end of the PHE scheduled to end May 11, many of those flexibilities are ending as well.

CMS’ document outlines how telehealth was allowed greater latitude during the pandemic, and how the Consolidated Appropriations Act of 2023 will extend many of those telehealth flexibilities through December 31, 2024. After the end of December, some Accountable Care Organizations (ACOs) may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live.

The PHE allowed a supervising healthcare professional to “virtually” supervise a trainee as opposed to “directly” supervise by being in the same room. That flexibility will continue through the end of December 2023. But the flexibility that allowed a certified registered nurse anesthetist (CRNA) to be supervised at the discretion of a hospital, as opposed to being under the direct supervision of a physician, will end on May 11. (But states can apply for a waiver.)

The CMS document also covers flexibilities relating to healthcare access and Hospital at Home programs.

Transitions

Deborah Wilson, the president & CEO of Lawrence General Hospital and a member of the MHA Board of Trustees, has announced her retirement from the hospital, effective May 2023. She has led Lawrence General since 2020 after previously serving as CFO and EVP. Until a new CEO is chosen, the hospital’s EVP and COO, Robin Hynds, R.N., will serve as the interim leader.

Susan Moffatt-Bruce, M.D., PhD, is the new president of Lahey Hospital & Medical Center. She most recently served as CEO of the Royal College of Physicians and Surgeons of Canada, a national professional association involved in medical education and the advancement of learning for specialty physicians. She concurrently served as CEO of Royal College International and was a faculty member of the Department of Surgery and a professor at the University of Ottawa. Previously, she led University Hospital, a 700-bed academic medical center of The Ohio State University Wexner Medical Center in Columbus, Ohio. Moffatt-Bruce earned her bachelor’s degree at McGill University in Montreal and completed medical school and her residency in general surgery at Dalhousie University in Halifax, Nova Scotia. She undertook a PhD in transplant immunology at the University of Cambridge, England, and completed her cardiothoracic surgery fellowship at Stanford University. At Lahey she succeeds David Longworth, M.D., who retired as president in December 2022. CMO Tim Liesching, M.D., served as interim president, and will now return to the CMO position.

John LoDico, Editor