Surprise Billing, New Safety Consortium, and more ....

Surprise Billing: Protect Patients, Negotiate Payments

Efforts are underway both in Washington and on Beacon Hill to help resolve the problem of “surprise billing.”
Surprise billing occurs when a patient receives care from an out-of-network provider that is not covered by their insurer. The most common scenarios occur when a patient needs emergency services and are cared for by an out-of-network physician or in an out-of-network facility, or a patient receives treatment at an in-network facility but is unknowingly cared for by an out-of-network clinician -- for example, by an anesthesiologist.
In these cases, all stakeholders currently debating the issue agree that patients should not be responsible for these unexpected bills, and that insurers and providers should work together to determine payment. The challenge centers on just how to determine an appropriate payment rate.
The Massachusetts legislature is addressing the issue, but whatever law the state may eventually pass will not cover the many people who are enrolled in self-funded, employer-sponsored plans regulated through the Employee Retirement Income Security Act of 1974 (ERISA). It will take federal legislation to apply surprise billing protections to those ERISA plans. Congress is debating three major pieces of bipartisan surprise billing legislation: a discussion draft from the House Energy and Commerce Committee entitled the No Surprises Act, a Senate bill from a working group led by Sens. Bill Cassidy (R-La.) and Maggie Hassan (D-N.H.) entitled STOP Surprise Medical Bills Act (S. 1531), and a discussion draft from the Senate Health, Education, Labor and Pensions (HELP) Committee entitled Lower Health Care Costs Act containing three separate options to address surprise billing.
As the debate continues, MHA has laid out some basic guidelines that hospitals believe should be part of any legislation – both state and federal.
First, patients should be protected from surprise bills and should pay no more than they would have paid if the service had been rendered in network. Second, for planned non-emergency care, patients should have easily accessible network information from their health plan. The most common way that individuals and families find in-network clinicians and hospitals is through their health plan’s provider directory. Patients should have access to comprehensive and accurate online provider directories through their health plan to know which providers and services are in their network. Health plans should also work with providers to ensure that they can provide patients with accurate information regarding network status. Additionally, health insurers must create and maintain robust provider networks so that out-of-network incidents are minimized.
Lastly, a fair and equitable reimbursement structure must be created that does not diminish the incentive for payers to negotiate fair rates or encourage providers to leave the network. The American Hospital Association (AHA) testified recently that Congress should “preserve the ability of providers and insurers to negotiate private contracts and not establish a fixed payment amount for out-of-network services. Arbitrary reimbursement rates could disrupt local market forces in ways that could have significant negative unintended consequences. Chief among them is the disincentive this will create for health plans to maintain adequate networks and act as good business partners to their providers. Without sufficient network adequacy requirements that address specific critical specialties and subspecialties, insurers can simply default to a benchmark payment and decline to contract with many different types of physicians.”
MHA supports using an independent dispute resolution process to resolve rate disagreements similar to the model adopted by NY State, as opposed to having a third party set default reimbursement rates.

A New Consortium to Focus on Patient Safety

The Betsy Lehman Center for Patient Safety has convened a group of 20 entities to work on a sustained effort to improve patient safety and healthcare quality throughout the health care continuum.
The goal of the consortium is to create a “Roadmap to Patient Safety,” which the Lehman Center describes as “a systematic approach to guide and energize future improvement efforts, with an emphasis on increased uptake of established best practices. The Roadmap will be structured around four interconnected pillars of patient safety: transparency, leadership and culture, learning health systems, and support for patients and the health care workforce.”
MHA has a seat on the panel. Pat Noga, R.N., MHA’s Vice President for Clinical Affairs, said, “Over the last several years, Massachusetts hospitals have made notable advances on patient safety, harm prevention and delivering high-quality care. Despite this progress, there is still more to do to improve care provided in hospitals and other healthcare settings. MHA and our members welcome the opportunity to continue to accelerate our work in these areas through the new Healthcare Safety and Quality Consortium.”
The 20 groups making up the new consortium are: Ariadne Labs, Blue Cross Blue Shield of MA, the Center for Health Information and Analysis, Coverys, CRICO: The Risk Management Foundation of the Harvard Medical Institutions, the Health Policy Commission, Healthcentric Advisors, Mass. Alliance for Communication and Resolution Following Medical Injury, Mass. Association of Ambulatory Surgical Centers, Mass. Coalition for the Prevention of Medical Errors, Mass. Health Quality Partners, Mass. Senior Care Association, MHA, Mass. Medical Society, Office of the Attorney General, Mass. Senior Care Association, Organization of Nurse Leaders, and the Quality & Patient Safety Division of the Mass. Board of Registration in Medicine.
Said Kim Hollon, the CEO of Signature Healthcare, Brockton and an MHA Board Member, “Senior leadership has to see patient safety and quality as the most important strategic initiative of the organization. They have to speak it, talk it” as well as learn how to implement learnings from other high-reliability industries in their organizations.

Brief Video Drives Home Importance of Hospitals

Attendees have provided very positive feedback about the recent MHA Annual Meeting, praising, among other elements, the diverse and engaging slate of speakers. One item that generated the most reaction was a brief in-house-produced video that MHA presented on Friday morning. Since it aired, some member hospitals have requested the video to show to their boards and internal teams. The 75-second video, entitled “They Come to Us,” shows, succinctly and movingly, the value of hospitals to the patients and communities they serve. It’s worth a look by clicking here.

Foundation Looking for a Plan to Improve Diagnoses

The Gordon and Betty Moore Foundation, dedicated to diagnostic performance improvement, is offering grants of $250,000 to $500,000 for the development and validation of new clinical measures to improve diagnoses in three areas: acute vascular events, infections, and cancer.
The Moore Foundation’s announced its Diagnostic Excellence Initiative that aims to reduce harm from erroneous or delayed diagnoses, reduce costs and redundancy in the diagnostic process, and improve health outcomes.
According to the online application form, successful grant entries will contain “a proposed measure of diagnostic performance based on obtainable evidence in one or more of the three priority categories … The expected work requires two interlinked activities: 1) development of the rationale for a measure and 2) operationalizing the measure into an algorithm that can undergo pilot (or proof-of-concept) testing…” Three to six grants will be awarded for work done over 12 to 18 months.

For more information, including the application form due back to the Moore Foundation by August 2, click here.

Boston Children’s: At the Top Six Years Running

Congratulations to Boston Children’s Hospital, which for the sixth consecutive year has been named the number one children’s hospital in the nation by U.S. News and World Report. (Children’s Hospital of Philadelphia was ranked number two.)
Massachusetts General Hospital was ranked number four in the U.S. News top 20 best hospital honor roll. ((The Mayo Clinic was number one this year.) Brigham and Women’s Hospital was ranked number 20.

"For our extraordinary team, this ranking is a badge of honor for the limitless dedication, imagination and compassion they bring to everything they do," said Boston Children’s President and COO Kevin B. Churchwell, M.D., who is also the treasurer of the MHA Board of Trustees.

MHA Seeks to Protect New Federal Liver Procurement Policy

The Department of Health and Human Services announced late last year that the Organ Procurement and Transplant Network and United Network for Organ Sharing (OPTN/UNOS) had approved a new liver distribution policy to establish greater consistency in the geographic areas used to match transplant candidates with available deceased donors. However, the new policy was threatened earlier this week when U.S. Representative Earl Blumenauer (D-Oregon) proposed an amendment to the House “minibus” spending bill which would have withheld funding to implement the new liver guidance. MHA joined the New England donor network in urging the Massachusetts delegation to oppose the amendment. Alexandra Glazier, president and CEO of the New England Donor Services, spoke for many New England healthcare stakeholders in her letter to Rep. James McGovern (D-Mass.), stating “the new organ distribution policy put the interest of patients first and better balances the ethical principles of equity, utility and autonomy in a way that maximizes these life-giving organ donations within the context of a just and fair system.” The amendment was ruled out of order during the Rules Committee consideration. McGovern chairs the Rules Committee.

Gaden Receives ONL’s Conceison Award

Congratulations to Nancy Gaden, the Senior VP and Chief Nursing Officer at Boston Medical Center, who last week at the Organization of Nurse Leaders’ annual meeting was presented the Mary B. Conceison Award for Excellence in Nursing Leadership. ONL’s highest award recognizes outstanding contributions made by a nursing service administrator. Conceison was director of professional relations at the Massachusetts Hospital Association for 12 years before her death in 1981.

Transition: VA’s Collins

John P. Collins, the executive director of the VA Central Western Massachusetts Health Care System for the past five years, has announced his retirement, effective in October. With Collins departure there are currently 10 open VA executive director positions around the country.

The Intersection of Human Trafficking and the Healthcare System: What Caregivers Need to Know

Friday, July 12, 2019; 8:30 a.m. - 1:30 p.m.
MHA Conference Center, Burlington, Mass.

Human trafficking is an ongoing public health threat that often goes undetected. The health system can play an important role in identifying and treating trafficking victims. From their immediate physical and emotional healthcare concerns to longer-term mental health and substance use issues, trafficking survivors often need a complex array of healthcare services. Mental health services are particularly important, as virtually all survivors have experienced some form of trauma. Because healthcare providers are in a unique position to identify victims and provide them with physical and psychological care, it’s critical that caregivers can identify the signs and find strategies to help their patients. At this conference, leading national and regional speakers – as well as a survivor of human trafficking – will provide an overview of this public health issue and discuss strategies and resources that providers can integrate into their organizations to better treat these victimized patients. New speakers have been added to the program in recent days. Click here to learn more.

John LoDico, Editor