SB626, SB624, HB601, HB2452-SB658, HB608, HB2224 Primary Care, Behavioral & Mental Health & Professional Practice

Joint Committee on Health Care Financing

The Massachusetts Health & Hospital Association (MHA), on behalf of our member hospitals, health systems, physician organizations and allied healthcare providers, appreciates the opportunity to submit comments on the following bills regarding primary care, behavioral and mental health and professional practice.

MHA strongly supports SB626, which would re-establish MassHealth’s contribution to medical education. MassHealth eliminated reimbursement for graduate medical education (GME) in the 2010 acute care hospital Request For Applications (RFA) after slowly reducing funding in previous years. MHA believes the disinvestment in physician training was an unwise policy and contributes to the Medicaid underpayment problem. More problematic, these investments are needed to support the next generation of physicians. Chapter 224 of the Acts of 2012 created a Special Commission on GME which found that “GME provides a wide range of benefits to the economy and overall health of the Commonwealth, including providing clinical care to many patients in the Commonwealth, in both the inpatient and outpatient settings that could not otherwise be provided; training the next generation of physicians to meet the medical needs of residents of the Commonwealth; providing valuable teaching services, such as in the education of medical students; promoting innovation in medical care and research; attracting and retaining talented faculty within the Commonwealth; providing highly specialized, cutting-edge care that is not available in non-academic settings; providing care to underserved populations; attracting grant funding; and contributing to the local economy.”1 The commission recommended additional funding for GME that is tied to performance benchmarks, including where there are physician shortages such as primary care, psychiatry, and general surgery. Since the entire commonwealth and all patients benefit from such training, all healthcare payers, including MassHealth, should be supportive of these programs. Forty-two state Medicaid programs across the country provide some measure of GME support. MHA respectfully requests the committee favorably report SB626.

MHA strongly supports SB624, which seeks to provide MassHealth members with access to coverage for emergency and urgent behavioral health services that is comparable to patient access for other acute medical conditions. SB624 supports the intent and requirements outlined in Sections 23 and 254 of Chapter 224 of the Acts of 2012– directing the implementation of the federal and state mental health parity laws. The legislature has shown its commitment to ensuring behavioral health parity throughout the state. Federal law already requires such parity and yet, for years, insurers and public coverage programs in Massachusetts have failed to abide by these laws, leaving behavioral health patients without the care they need and deserve. While Chapter 224 set in place the basic requirements, recent reports from the state have shown failure in meeting these parity principles. Stronger protections are needed to ensure that MassHealth is actually providing equal access for behavioral health patients. SB624 will help ensure that the MassHealth program is truly adopting regulations, policies, and procedures for behavioral health services that are on par with the rules adopted for patients with other acute medical conditions.

MHA also supports HB601, which would allocate a portion of the health workforce trust fund to support training and hiring of mental health workers. Stable and appropriate community-based service providers are essential and will help minimize substance abuse user disorders and opioid overdoses. A major factor in the opioid abuse epidemic is the lack of available community-based placements to care for patients. The current shortage of qualified professionals results in extended wait times and delayed access to care. Proposals such as HB601 will increase the number of providers available to serve addicts and others with mental health disorders and enhance care and treatment throughout the commonwealth.

With regards to HB2452/SB658, MHA supports the expansion of scope of practice for all Advanced Practice Registered Nurses– nurse practitioners, certified registered nurse anesthetists, psychiatric clinical nurse specialists, and certified nurse midwives. The various bills that have been filed on this issue allow certain APRNs to have pathways to independent practice authority. MHA is supportive of proposals to require additional post-graduate training prior to full practice authority or independent practice, including some sort of orientation, mentorship, or preceptorship, as well as allowing advanced practice nurses the ability to supervise the process of their fellow nurses toward independent practice authority.

APRNs should also be held to the same standards of transparency, accountability, and professional responsibility under which physicians practice. This includes Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), public reporting to the Department of Public Health or Board of Registration in Nursing, quality reporting tied to the practitioner, public reporting of medical malpractice awards or settlements, mandated medical malpractice liability policy limits, public reporting of any arrangements between practitioner and the pharmaceutical industry, continuing education requirements, and peer review. And just like physicians, APRNs currently must carry professional liability insurance in order to practice.

APRNs are guided by specialty-related national and local standards of care, their education and training, as well as by specific regulations governing their scope of practice. Consistent with The Joint Commission recommendations, OPPE is appropriate for all clinicians, including APRNs. There may be gaps in organizational structures supporting OPPE and, where there is appropriate movement towards full practice authority, steps should be taken to ensure that structure and accountability is the same for all licensed independent providers. At the institutional level, scope of practice should be determined by education, training and experience for APRNs just as is done for physicians. It should be expected and verified that an individual’s practice is within his/her education, training, and experience, and that he/she functions within professional boundaries with ongoing professional evaluations.

MHA opposes HB608. This legislation significantly alters the legislature’s judgement and consideration of any proposal to change the scope of practice of a licensed healthcare provider. The bill would require the Health Policy Commission (HPC), upon the request of the Joint Committee on Health Care Financing, to conduct a review and examination of such proposals. The bill then sets forth a set of strict changes to legislative rules to govern the legislative debate and procedures dependent upon the HPC findings. MHA believes this proposed entwinement of the HPC with the legislative process is highly improper and would simply divert resources needed to accomplish HPC’s current role and responsibilities.

MHA also opposes SB615, which is intended to add a nurse to the list of Health Policy Commission (HPC) Board members. MHA and many other groups have advocated for a reconsideration of the board membership on the Health Policy Commission, to ensure that it best reflects the knowledge and perspective of provider groups that are directly affected by the policies and practices of the agency. However, the sole inclusion of a nurse with no broader reconsideration of stakeholder representation is inappropriate. While we disagree with the specific language of SB615, we would support an effort by the legislature to reconsider the make-up of the HPC to include a broader cross-section of appropriate healthcare providers, including nurses, who are actively practicing and have first-hand, on-the-ground knowledge of the current changes within the healthcare environment.

MHA strongly opposes HB2224, which would allow different co-payment rates to apply to nurse practitioners and physician assistants for providing the same service as physicians. This would create additional administrative burdens for providers and practices as they would have to determine different co-payments for different provider types. It would also lead to confusion and anger among patients who sometimes may have higher co-pays and sometimes lower co-pays depending upon who they see. It is analogous to different tiers within the same practice, which causes the same kind of administrative burden for practices and should also not be allowed. The co-pay for patients should be based on the service provided, not on WHO provides it.

Thank you for your consideration of these important matters. If you any questions or need further information, please do not hesitate to contact Michael Sroczynski, MHA’s Vice President of Government Advocacy at (781) 262-6055 or msroczynski@mhalink.org.

1 http://www.mass.gov/eohhs/docs/eohhs/gme-final-report.pdf