HB971, HB931, SB542, HB1009, HB976, HB1045, SB622, HB1003
Health Care Legislation

Joint Committee on Financial Services

The Massachusetts Health & Hospital Association (MHA), on behalf of its member hospitals and health systems, physician organizations and allied health care providers, appreciates this opportunity to offer its comments in regards to various bills that deal with health insurers and providers in Massachusetts.

Mobile integrated health (MIH) is the practice of utilizing community paramedicine to provide healthcare services to non-emergent patients, in coordination with healthcare facilities and other providers. These programs, reviewed and approved by the Department of Public Health, ensure that patients receive appropriate care services at the right place at the right time, ultimately minimizing hospital readmissions and unnecessary visits to emergency departments. However, providers have been hesitant to invest in the resources necessary to establish MIH programs, as there is currently no guarantee that the healthcare services provided through MIH will be reimbursed by public and private insurance plans. MHA supports HB971 as it would disallow these insurance carriers from refusing to cover healthcare services on the basis that they were delivered by a state-approved MIH program, and requires that said services be covered to the same extent as they would have had they been provided in a healthcare facility.

MHA supports the intent of HB931 and its goals to minimize administrative complexity and provide high value and high quality patient care. Specifically, we agree that more transparency in prescription drug spending is necessary to address the continuing rise in costs, which rose 5.8% between 2017 and 2018 and accounted for the majority of growth in total health care expenditures. MHA also supports the establishment of a common set of quality measures that would be used by commercial payers as well as MassHealth. Implementing a common set of quality measures will enable providers to reduce the administrative burden and simultaneously focus on specific areas of quality improvement. Additionally, HB931 affords important peer review protections to accountable care organizations (ACOs) that will facilitate candid conversations about quality improvement. The bill also strengthens a provision of the disclosure, apology, offer, and acceptance laws by clarifying that payments made as the result of this process need not be reported as malpractice settlement payments. MHA also applauds the provisions of the bill that require insurance coverage parity and reimbursement for telemedicine services. Telemedicine increases quality and efficiency in the healthcare system while providing convenient care for patients. Lastly, MHA supports the intent of the out of network billing provisions which would hold patients harmless for surprise bills and establish a fair process for paying for the services rendered by out of network providers.

MHA supports SB542, which furthers the goals of the statewide end-of-life campaign by ensuring that appropriate and coordinated communication with patients about end-of-life treatment options by insurers or other care providers are done with the knowledge of the patient’s treating provider. End-of-life care typically incudes both medical and behavioral health palliative services to ease the pain and emotional burden experienced by a patient and their family. As such, it is important that the patient’s entire care team is aware of the discussions and plans. Doing so will minimize the chance for confusing or conflicting messages and care plans, and provide assurance that all appropriate parties (including the utilization review or care coordination team within an ACO or health plan) are working together and not separately.

MHA is supportive of the intent of HB1009. This bill imposes the liability for unpaid patient deductibles and co-payments on health insurers and requires them to reimburse healthcare providers for any such amounts. This bill is similar to MHA’s own bill HB976 which is more comprehensive and provides clear direction as to the circumstances and the methods for when carriers should reimburse providers for unpaid patient liabilities.

Under current policies, insurers may inform patients to refuse payment at the time of service and similarly instruct providers to wait until a claim is adjudicated before billing a patient. In emergency situations, hospitals may not even know which insurance plan covers a specific patient, making it impossible (and illegal under EMTALA requirements) to collect any patient obligations at the time of service. Therefore, the burden of uncollectible patient debt is born entirely by the providers, who must deal with many issues, including: patients’ confusion about their financial responsibilities; spending considerable time and money trying to collect the patient’s debt; and ultimately, writing-off millions of dollars in bad debt when patients cannot pay the amounts owed.

HB976 requires carriers, who design and sell these plans, to share accountability with providers for uncollectible patient obligations after insurance. This legislation would require insurers to reimburse healthcare providers 65% of an uncollected co-payment, co-insurance, and/or deductible that exceeds $250 if the provider does not receive payment after it has made reasonable collection efforts. The process for reasonable collection efforts outlined in the bill is similar to the processes used by Medicare and the state’s Health Safety Net, with the 65% reimbursement similar to the Medicare methodology.

HB0145 requires provider organizations and carriers to, upon request, give consumers the allowed amount or charge for services, including facility fees. This first section of the bill essentially mirrors what is already law under Chapter 224 but actually weakens the requirement for carriers who currently must provide real-time estimates, instead of two working days under the proposed bill. The bill also creates an incentive program that encourages patients to shop for services and if they can find a less expensive alternative (i.e., one that costs less than the average price paid by that insurer for that service), they would receive a rebate. Patients may choose either in-network or out-of-network providers.

While MHA appreciates the intent of HB1045, there are numerous clinical and logistical concerns that arise. Most importantly, it will make it difficult or impossible for primary care physicians (PCPs) to manage patient care. As the commonwealth promotes integration of care, patient centered medical homes and ACOs, which require PCPs and others to be aware of where and how a patient is receiving care, this bill will encourage the exact opposite. There is nothing to prevent a patient from looking for the cheapest place to get an MRI and then calling the PCP and requesting that he be referred to that location, which may not even be in their insurer’s network. The bill does nothing to encourage patients to consider care quality in addition to price. For patients who have HMOs that require referrals for any services requiring prior authorization, this can potentially put the patient, their physician, and insurer at odds with one another, lead to delays in getting care, make it difficult for physicians to provide clinical information and to obtain results from a provider they never work with, and will not necessarily benefit the patient. MHA would like to work with the committee on enhancing opportunities for consumers to seek and obtain appropriate and relevant cost information that can be shared with their clinicians so that there can be a reasonable discussion about price and out-of-pocket costs that also consider what’s best for the patient. Shopping for health care services is not the same as shopping for a new television; encouraging patients to find the cheapest provider simply to get a rebate without considering quality, a patient’s health status, electronic health record connectivity, provider and insurer networks, and referral and authorization requirements is not good medicine.

MHA strongly opposes SB622, as it is both unnecessary and can potentially disrupt continuity of care. This bill would prohibit facilities from taking action against providers for referring a patient to an outside facility or provider that’s not part of the same health system if the provider believes the referral is in the patient’s best interest or if the patient requests the referral. This bill proposes to address a problem that doesn’t exist. If a medically necessary service is unavailable within a provider’s own provider organization or system, that provider will of course seek the treatment elsewhere and will not be “punished” by the “health care facility” for doing so. Allowing patients to simply request to go elsewhere, as would happen with this legislation, is contrary to building integrated systems of care such as ACOs and patient centered medical homes. In addition, HMO members could wind up with bills for out of network services. There are existing patient protections in statute, including specific appeal rights for patients in risk based provider organizations and ACOs.

MHA opposes HB1003, which would amend health insurance statutes to specify which metrics may and may not be used in determining alternative payment arrangements. It permits the use of age, acuity, social determinants of health, and behavioral health needs – while prohibiting the use of historic price trends – when assessing the users of a particular provider. It would also require the disclosure of data used in pricing determinations and establishes that use of prohibited data or failure to disclose data to the Center for Health Information and Analysis is to be considered an unfair business practice under GL 93A. MHA opposes this legislation as it would be administratively complex to adopt and does not take into account numerous nuances in provider prices. Such a proposal would need to be modeled and tested significantly before being considered and implemented.

Thank you for the opportunity to offer testimony on this matter. If you have any questions regarding this testimony, or require further information, please contact Michael Sroczynski, MHA's Senior Vice President of Government Advocacy at (781) 262-6055 or msroczynski@mhalink.org