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The Honorable T. Eloise Foster The Honorable Peter Hammen September 28, 2010 Page 1 September 28, 2010 The Honorable T. Eloise Foster, Co-Chair Secretary, Department of Budget and Management The Honorable Peter Hammen, Co-Chair Chairman, House Health and Government Operations Committee Health Care Delivery System Workgroup Health Care Reform Coordinating Council Dear Co-Chairs Foster and Hammen: On behalf of the 67 members of the Maryland Hospital Association (MHA), we are writing to share our comments on the key issues being discussed by the Health Care Delivery System Workgroup of the Maryland Health Care Reform Coordinating Council (HCRCC). In August 2009, MHA convened a Task Force on the Future of Payment in Maryland. Its members, which included a broad range of member hospital CEOs and trustees, assessed how multiple national and local trends, including the prospects of national health care reform, would affect the future of health care in Maryland, specifically Maryland’s unique hospital rate-setting system. Among these trends were the increasing number of uninsured and underinsured Marylanders, growing Medicaid enrollment, burgeoning health care costs, workforce shortages, consolidation among insurers and providers, and an uncertain financial environment. The Task Force also considered how the last three decades have affected how and where providers and patients interact; the mounting burden of chronic disease, which demand ...
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The Honorable T. Eloise Foster
The Honorable Peter Hammen
September 28, 2010
Page 1
- more -
September 28, 2010
The Honorable T. Eloise Foster, Co-Chair
Secretary, Department of Budget and Management
The Honorable Peter Hammen, Co-Chair
Chairman, House Health and Government Operations Committee
Health Care Delivery System Workgroup
Health Care Reform Coordinating Council
Dear Co-Chairs Foster and Hammen:
On behalf of the 67 members of the Maryland Hospital Association (MHA), we are writing to
share our comments on the key issues being discussed by the Health Care Delivery System
Workgroup of the Maryland Health Care Reform Coordinating Council (HCRCC).
In August 2009, MHA convened a Task Force on the Future of Payment in Maryland.
Its
members, which included a broad range of member hospital CEOs and trustees, assessed how
multiple national and local trends, including the prospects of national health care reform, would
affect the future of health care in Maryland, specifically Maryland’s unique hospital rate-setting
system.
Among these trends were the increasing number of uninsured and underinsured
Marylanders, growing Medicaid enrollment, burgeoning health care costs, workforce shortages,
consolidation among insurers and providers, and an uncertain financial environment.
The Task
Force also considered how the last three decades have affected how and where providers and
patients interact; the mounting burden of chronic disease, which demand new and different
efforts to coordinate care and improve outcomes; and the growing role of non-inpatient facilities
and providers, which requires collaboration across multiple care settings.
The Task Force’s goal
was to develop a framework to address the future needs of all patients--both the newly insured
and those that continue to be uninsured; the reality hospitals face today; and strategies to allow
the system to continue to uphold its founding principles:
efficiency, accessibility, equity, and
solvency.
Through this Task Force process, MHA members identified two priority shifts for the future of
the Maryland system.
The first involves transitioning to a system that is focused on the health of
patients and communities.
The second calls for a system that encompasses a broader set of
performance measures, which will allow for new kinds of policy experimentation and encourage
providers to coordinate, collaborate, and realign to achieve the best outcomes for Marylanders.
Achieving such a transition will require a coordinated effort among multiple stakeholders.
While
an episode-based payment mechanism as described at the Workgroup’s August 25 meeting holds
merit, MHA cannot offer a position on this approach until further analysis and/or modeling
The Honorable T. Eloise Foster
The Honorable Peter Hammen
September 28, 2010
Page 2
is completed.
Ensuring that sufficient funding is available to implement future performance
improvement activities, including a successful preventable readmissions reduction program as
well as shared savings between providers and payors, as contemplated nationally by the
Medicare program, is critical.
The past two years of annual hospital updates have simply not
been enough to allow hospitals the resources needed to implement such improvements.
The
Health Services Cost Review Commission has agreed to revisit the issue later this fall.
To specifically respond to the many questions posed by the Workgroup in its discussion
document, we have included two attachments.
The first responds to the areas of requested public
input as outlined in the Workgroup’s Key Issues for Public Comment document; the second
outlines specific Maryland hospital initiatives that are currently in place to address many of these
same subject areas.
Health reform represents an exciting opportunity for Maryland to be creative and innovative in
bringing Marylanders the best care possible.
We look forward to working with other
stakeholders to create a delivery system that promotes better health for all Marylanders and a
stable environment for the providers who take care of them.
Transitioning from the present
system to the future system in a manner that is least disruptive to patients, providers, and
policymakers will be key.
MHA appreciates the opportunity to comment on these key issues, and we look forward to
working together to move Maryland’s health care reform efforts forward in a timely, thoughtful,
and inclusive manner.
Sincerely,
Valerie Shearer Overton
Michael Robbins
Senior Vice President, Legislative Policy
Senior Vice President, Financial Policy
Addendum Attached
Health Care Delivery System Workgroup Addendum
Page 1
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Addressing the Cost Drivers of the Health Care System
•
Implement Patient Centered Medical Home Initiative and ensure that:
-
Upfront funding is adequate to make it successful; and
-
Focus is directed at those with multiple chronic conditions to maximize cost savings
potential.
•
Strengthen Healthiest Maryland Initiative.
•
Focus on reducing provider administrative costs (2005 article from Health Affairs estimated
hospital administrative expenses at 21 percent, of which billing and insurance related costs
were 11 percent; physicians were 27 percent, with billing and insurance related costs at
14 percent).
Promote Evidence Based Practices
•
State should establish mechanism for dissemination of evidenced based practices research
and not duplicate the extensive work being done at the national level.
•
State should continue the work of the Governor’s Quality Council--central line blood stream
infections, hand hygiene, blood wastage, etc.
Payment Reform
•
Stabilize funding for Medicaid and plan for funding of additional state costs under federal
health care reform.
-
Averted uncompensated care assessment--the current prospective reductions due to
poorly estimated averted uncompensated care should end until all reconciliations have
been completed to the satisfaction of policymakers and reconciled with actual hospital
experience.
•
Ensure Health Services Cost Review Commission (HSCRC) readmissions policy focuses on
“preventable” readmissions and not hold hospitals accountable for operating in a community
that may lack pre- and post-acute outpatient resources.
•
Promote experimentation and demonstration via HSCRC Alternative Rate Methodology--a
tested mechanism that currently exists.
•
Determine what, if any, changes are needed to the waiver/HSCRC to accommodate/promote
development of accountable care organizations in Maryland.
Health Care Delivery System Workgroup Addendum
Page 2
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Delivery System Reform
•
Educate self-funded employees on benefits of PCMHs
-
MHA effort underway to educate and enroll as many hospitals as possible in Maryland
Health Care Commission PCMH program.
•
At federal level, determine what changes are needed to antitrust, Stark, anti-kickback, civil
monetary penalties, etc., to remove legal barriers to successful development of ACOs.
Grants, Demonstration Projects, and Pilots for Maryland
•
Section 3022 – Medicare shared savings program.
•
Section 2703 – State option to provide health homes for enrollees with chronic conditions.
•
Section 3504 – Design and implementation of regionalized system for emergency care.
•
Section 5405 – Primary Care Extension Program.
Examples of Specific Hospital Initiatives Currently Underway
Readmissions
•
Internal committee:
-
Analyzed highest readmission diagnoses and identified several potential factors;
conducted four-month case-matched survey of patients readmitted and those not
readmitted who had the same diagnosis;
-
Participating in an eight-hospital trial patient follow-up protocol with interventions when
patients have difficulty with instructions, PCP appointments, or meds; follow-up program
for comparison;
-
In discussions with nursing/rehab facilities to pilot a collaborative project to reduce
readmissions;
-
Working with Wound Center to introduce a chronic disease management program for
diabetic patients; and
-
Physician integration--key focus is use of an extensive EHR and coordination among
hospital-based and nonhospital-based providers through medical home type model.
•
All paid for by hospital through operating revenue--not rate adjustments.
Access to Primary Care
•
Hospital-operated community health center (not on the hospital campus) that provide no-cost
and low-cost care to area residents.
Health Care Delivery System Workgroup Addendum
Page 3
•
Local center sees 6,000 patient visits annually and is opening an additional center to provide
care to the working poor and underinsured on a sliding-fee scale basis.
-
Staffed by multi-lingual health professionals, it seeks to provide care close to where
people live, and to address primary care as well as social needs.
-
Anticipating some 60,000 patient visits within the first five years of operation of second
center (12,000 annually).
-
Expectation is that access to high quality primary care will reduce the burden on the acute
care side.
Prevention and Care Coordination
•
Hospitals investing in health screening and patient education, especially collaborations with
community-based groups that may already conduct such community screenings.
-
Integrating community-based screening programs with hospital-operated community
health centers in the near future to expand access to screenings.
•
Investments in care coordination through a system of nurse and other navigators, especially
in oncology, to assist patients in navigating through complex diagnosis.
-
Reduces costly duplicative testing and related services.
•
Expanding palliative care and pain programs to deliver more effective care and to help
educate patients and families on appropriate care.
Utilization Review/Documentation
•
Adoption of software systems that monitor utilization of hospital resources and allow for
benchmarking against peer (physician) groups.
-
Focuses on quality metrics and allocation of resources, with the goal of improving
overall quality while reducing cost.
-
Also seeks to reduce duplication and prevent unnecessary procedures.
Supply Chain Management
•
More efficient focus on medical and hospital supplies to reduce expenses.
