INSIDE THE ISSUE

> Awaiting Chap. 260 Regulations
> BMC’s TEAM UP Method
> National Healthcare Decisions Month
> The Second Booster
> Verdict in Medical Error Case

MONDAY REPORT

Without Telemedicine Map, Insurers Chart Their Own Course

Because the Division of Insurance (DOI) has not yet issued regulations to implement Chapter 260 – the innovative law that governs, among other things, payment parity in perpetuity for behavioral health services delivered via telemedicine – insurers are free to create their own implementation plans subject to DOI’s approval.

Karen Granoff, MHA’s senior director of Managed Care, said, “If there is one thing the pandemic taught us is that telemedicine can improve access to, and delivery of, healthcare services. The legislature and governor recognized this with the passage and signing of Chapter 260. But now, given the lag in issuing regulations, insurers when left to their own interpretations of the law can create confusion in the marketplace for both patients and providers.”

Chapter 260 of the Acts of 2020, An Act Promoting a Resilient Health Care System that Puts Patients First, was signed into law in January 2021 and mandates telehealth coverage parity across all payers – including MassHealth and the Group Insurance Commission. Notably, the law requires MassHealth and commercial insurers to provide permanent coverage of tele-behavioral health services, and to reimburse those services on par with in-person services. Additionally, primary care and chronic disease management services (including cancer, stroke, and coronary artery disease) are to be reimbursed at the same rate as in-person services for two years from the effective date of the legislation – which is only through December 31, 2022.

With passage of the law, the Division of Insurance is required to draft the regulations to implement it; those as-yet-to-be-drafted rules will define the minimum standards health insurers must meet to be accredited for telehealth services. DOI held listening sessions last year to assist it in drafting the regulations. However, the regulations are still unwritten, meaning health insurance companies can create their own definitions of what constitutes, for example, behavioral health, chronic disease management, and primary care services, as well as offer their own guidelines for provider location, telehealth platforms, and required documentation.

“The tMED Coalition is concerned that this lack of guidance from the state has led to chaos and confusion in the marketplace for healthcare providers and patients,” the group wrote to DOI Commissioner Gary Anderson in February. “The lack of overall guidance means that it is likely each insurer may not take the same approach to defining service categories or identifying provider types that may be reimbursed at parity for such services.”

On Friday, April 1, a new telehealth policy from Blue Cross Blue Shield of Massachusetts became effective. It includes a 20% cut in reimbursement for non-behavioral health, non-primary care providers using telehealth, as well as for diagnoses that Blue Cross does not define as “chronic conditions.” Providers are concerned because it is unclear how they will be paid for certain services, with the provider type rather than the service provided determining the payment. For example, to be paid in parity with in-person services for behavioral health, the caregiver must be enrolled with Blue Cross as a licensed a behavioral health provider. Likewise, an OB/GYN providing primary care services to her patients would be paid 20% less than her primary care counterpart for the same service. Providers were hopeful that the DOI regulatory process would give them the opportunity to comment on draft regulations and, ultimately, create predictability and reliability – no matter who the telehealth provider is.

In addition to reimbursement issues, the tMED Coalition in its March letter to Blue Cross Blue Shield outlined specific concerns relating to how the insurer was interpreting non-chronic diagnosis claims. For example, Blue Cross’s list of chronic conditions applies predominantly to geriatric populations and does not include conditions such as opioid use disorder or sickle cell disease. “We are concerned that this list is not inclusive of many chronic conditions, especially those affecting our pediatric populations, who benefit greatly from the flexibilities of [telehealth] as well,” the tMED Coalition wrote, adding that the Blue Cross policy appears to fall short in reimbursing on par for telehealth services that address developmental disorders despite the fact that clinicians are providing the same services as they would through in-person visits.

“Chapter 260 created a new telemedicine landscape in Massachusetts,” MHA’s Granoff said. “Healthcare providers need the state to move expeditiously to create the regulatory map to guide us through that landscape so we can avoid the pitfalls we’re seeing when health insurance companies are allowed to craft their own interpretations.”

BMC’s TEAM UP Model Provides One Answer to Youth Mental Health Crisis

As the behavioral health boarding numbers show (see story below), the situation in Massachusetts continues to worsen for children, who have been especially hard hit with mental health issues during the pandemic.

Now a new study from Boston Medical Center and Boston University School of Public Health shows that a care model that integrates behavioral healthcare into pediatric primary care at federally qualified health centers can have demonstrable results in improving care for all children, but especially racially and ethnically marginalized children who are more likely to access care at the federal centers.

The BMC/BU study focused on the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model BMC developed. Through TEAM UP, a behavioral health screening was completed at more than 81% of well-child visits at the three federally qualified health centers; that’s better than the state average of 74%. The study showed that if a child received a “warm hand-off” from their primary care provider to behavioral health staff they were more likely to complete an additional visit.

“We know that before the pandemic, more than 15% of children in the United States had a behavioral health condition, with impoverished children bearing disproportionate risk,” said R. Christopher Sheldrick, PhD, evaluation co-director of TEAM UP for Children at Boston Medical Center and a research associate professor of health law, policy, and management at Boston University School of Public Health. “Now that there are surging numbers of children requiring behavioral health support following the COVID-19 pandemic, this is the type of model that needs to be replicated to ensure equitable access across the United States.”

Read the study in Pediatrics (Volume 149, Issue 4; April 2022).

April is the Time to Focus on Advance Care Planning

April is National Healthcare Decisions Month, which is when attention turns to empowering people to think about their care goals and choices to make sure they can receive the medical care they want even if they are not in a position to articulate it themselves.

Throughout this month and beyond, providers are encouraging patients and families to focus on their care wishes and the process that they want their loved ones and caregivers to follow if they become seriously ill. One of the easiest ways to start this process is to designate someone as a healthcare agent and make sure that agent knows the person’s wishes by filling out a simple healthcare proxy.

Lots of information exists to start people down the advance care planning path. Visit PatientCareLink.org and then click on Healthcare Planning Throughout Your Life under the For Patients & Families tab, or Serious Illness Care under Improving Patient Care.

Honoring Choices Massachusetts also is tremendous resource to walk people step-by-step through the advance planning process.

Second Boosters Okayed

Anyone age 50 and older may now get a second booster at least 4 months after their first booster. People can mix and match vaccines; the second booster does not need to be the same vaccine brand as your original COVID-19 vaccination or booster. Visit vaxfinder.mass.gov for a list of locations offering a booster. Residents will be able to narrow results to search for locations that are offering the booster of their choice. Learn everything you need to know about vaccines in Massachusetts at this state site.

A Chilling Medical Errors Verdict in Tennessee

Former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted last week of gross neglect of an impaired adult and negligent homicide for mistakenly administering the wrong medication to an elderly patient in 2017. She will be sentenced on May 13 and could face up to six years in prison.

The charges against her and the subsequent trial generated national concern among healthcare interests. Medical errors, although tragic, are very rarely prosecuted. Each error in a hospital leads to serious internal review to investigate all aspects of what went wrong – whether it be mislabeling of drugs, improper signoffs and approvals, chain-of-command breakdowns, fatigue, or other factors. The intention is to improve the part of the care system that failed.

MHA’s Vice President of Clinical Affairs Patricia Noga, and Amanda Stefancyk Oberlies, CEO of the Organizations of Nurse Leaders, said following the verdict in Tennessee last week, “The Massachusetts healthcare community has spent decades fostering a culture of transparency when it comes to the reporting of medical errors. Our nurse leaders and hospitals stand strongly behind the time-tested standards in place, which recognize that errors are most often the result of systems and protocols that require improvement. Most importantly, this approach empowers clinicians to practice with honesty and without fear. This fundamental philosophy is a lynchpin in the delivery of safe, world-class care – the care that the commonwealth’s patients deserve.”

In Massachusetts, the Coalition for the Prevention of Medical Errors, of which MHA is a founding member, has been a leader in this area. And many providers have adopted the Communication, Apology, and Resolution (CARe) model from the Mass. Alliance for Communication and Resolution Following Medical Injury. Through CARe, provider organizations promptly disclose what is known about the harm event or unexpected outcome to patients and their families; investigate the root causes of the event; share information with patients and families in a timely manner; and, in cases of preventable harm, offer patients and family members a sincere apology and financial restitution without litigation.

John LoDico, Editor