SB1174, HB1181/SB1183, SB1269, HB1136, HB1137, HB1207, HB3250, SB1248, SB1270, HB1175, HB1197, SB1230, HB2441, HB2477, HB3514, SB1212, SB1234
Healthcare Facilities

The Massachusetts Health & Hospital Association, on behalf of its member hospitals, health systems, physician organizations and allied healthcare providers, appreciates this opportunity to offer comments regarding the following legislation regarding hospitals and other healthcare facilities.

MHA supports SB1174, which seeks to expand the activities and efforts of the sexual assault nurse examiner (SANE) program in all acute care hospitals in Massachusetts. In particular, SB1174 would also require the state to improve the collection and transport of sexual assault evidence collection kits to prevent loss or delays in delivering this important information for use by public safety officers and the court system. MHA and our member hospitals strongly support the improvement and expansion of the SANE program and are working closely with the Department of Public Health and other stakeholders to find viable funding options to sustain the program. While the hospital community is strongly supportive of this program, we are concerned with the provisions within Section 5 of the bill (specifically the new MGL Chapter 111, section 220, Subpart M), which are proposing to adopt a fee structure for facilities to be designated as a SANE facility and determining who participates in statewide SANE training programs. If hospitals are now required to pay for the use of state employees to conduct a SANE examination for criminal proceedings, this will create a significant financial constraint on the hospital to also provide many follow-up services to patients in the emergency department. While it is critical to find reasonable funding solutions to extend the SANE program, requiring providers to pay for such services that are not reimbursed by any payer will prevent many facilities from seeking to be designated as a SANE facility. So we strongly urge the committee to consider this specific subsection in the bill and the access concerns it may cause.

MHA opposes HB1181/SB1183. This bill would put in place additional regulatory oversight and reporting requirements on healthcare providers related to pain management medication and the prescribing of Schedule II controlled substances. Currently, all healthcare professionals, as part of their training and ongoing quality review programs, must assess the appropriate treatment needs of their patients based on the clinical presentation of the patient and the services that are sought. Numerous quality and licensing oversight standards – including The Joint Commission (TJC) standards for the provision of care and patient rights, the Centers for Medicare and Medicaid Services (CMS) conditions of participation, and the Massachusetts Board of Registration in Medicine patient care assessment provisions – already require healthcare facilities and health professionals to plan, support and coordinate activities and resources for patients to ensure that pain is recognized and, if controlled substances are needed, that they are administered in an appropriate manner in accordance with the care, treatment, and services provided to patients. These standards also include ongoing education concerning the assessment and management of pain, the effects of pain management, and the prescribing of controlled substances during treatment for all patients and their families. As such, we believe the provisions included in HB1181/SB1183 would be duplicative of existing standards without identifying the appropriate information and data necessary to enhance patient care for the citizens of the commonwealth.

MHA is opposed to SB1269. This past April 2017, the DPH issued revised licensure regulations that already require hospitals to provide specific operational and access information related to any pending closure of an essential service. Hospitals are also required to provide notice of the closure to the general public, employees, legislators and other state agencies that are affected by the closure. In addition, a hospital is already required to submit this information to the Health Policy Commission, which has the authority to share this information with the Attorney General’s office for further review. For these reasons it does not make sense to add additional requirements for an essential services review that would add conflicting requirements to the existing process. For these reasons, we urge the committee to oppose SB1269.

MHA is opposed to HB1136. While hospital officials routinely meet with interested stakeholders and community groups to discuss key issues affecting the delivery of care, it is neither feasible nor appropriate to mandate the way that hospitals meet with their communities. Given the diverse nature of many community interests, multiple communities within specific service areas, and the complexity of hospital organizations, flexibility is needed. While community-based conversations should be encouraged and fostered, hospitals must be afforded sufficient flexibility in the manner and form of their engagement with local communities. The mandate proposed by HB1136 misses the mark by a wide margin.

MHA is also opposed to HB1137. All hospital governing boards in Massachusetts are composed of unpaid, volunteer, community-based representatives. Board members receive training from legal staff and are kept closely apprised of their ethical and fiduciary responsibilities. The training is often tailored in a manner that best serves the unique needs and orientation of the hospital and the varying roles in which the trustee will be involved. Under HB1137, these volunteer board members would be forced to complete a state-approved, seven-hour training course led by a DPH-certified and approved trainer. Such a mandate is improper and misguided, especially when there is absolutely no evidence that hospital board members in the commonwealth are failing to uphold their ethical and fiduciary responsibilities. The committee should reject this inappropriate legislation.

MHA opposes HB1207. This bill would require every hospital to maintain written directives in surgical and intensive care units on hand washing, use of chlorhexidine antiseptic, placement of sterile drapes over a patient’s entire body, the wearing of sterile gowns, hats, masks and gloves, and the placement of sterile dressings over a catheter site once a line is inserted. Massachusetts hospitals take the duty of providing a sterile field environment seriously. However, simply requiring signage and additional paperwork as suggested by HB1207 will do nothing to promote aseptic technique. Further, many of these procedures are already standard operating procedure that hospitals are required to follow based on licensure rules, national accreditation standards, and local medical standards of care adopted by hospital medical staff. Simply requiring signage in the hospital that suggests the appropriate hygiene protocols provides no intrinsic value. MHA believes that existing mandatory requirements for orientation, training, annual re-training, and routine internal review of practices as mandated by accreditation organizations are far more effective techniques to reinforce sterile practice. Further, all hospitals are subject to three National Patient Safety Goals (NPSG) specific to implementation of evidence-based practices to prevent Healthcare Associated Infections (HAIs) and the National Patient Safety Goals to comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Accreditation survey findings and compliance with these NPSGs are posted on a public website. It is very important to reiterate that all hospitals support and are committed to developing internal practices that will lead to decreased infections and better patient outcomes, but simply mandating signs and paperwork will not be effective tools. There are numerous ongoing provider safety efforts that are producing meaningful change. For example, MHA’s member Culture of Unit Safety Program to Prevent Central Line-Associated Infections (CUSP-CLABSI) has demonstrated a significant difference in hospital culture and CLABSI rates. We would welcome the opportunity to further discuss all of these initiatives with committee staff and discuss why adding unnecessary signage does nothing but add paperwork requirements without improving the health and safety of patients.

MHA is opposed to HB3250. Every healthcare provider supports and uses an informed consent process prior to performing any medical procedure that includes those that may include the administration of pharmaceuticals. It is also a national standard of practice to develop a uniform consent form that would cover all aspects of the care and treatment of a patient. Developing separate forms and consent requirements for various treatments and/or services not only adds confusion for the patient, but potentially leads to increased risk of treatment delays. HB3250 seeks to impose unrealistic and troubling informed consent requirements prior to the administration of psychotropic drugs within certain healthcare facilities, including hospitals. While healthcare providers support the appropriate limitations on the use of psychotropic drugs, we are strongly concerned with the adoption of duplicative and unnecessary paperwork burdens on providers that will not improve care. HB3250 would require healthcare providers to secure a separate and distinct oral consent from patients or their legal guardians prior to administering such drugs – in addition to obtaining an informed consent prior to treatment. Such a requirement will only delay care and treatment for patients who are often going through a psychiatric episode and pose a danger to themselves and others. In addition, we are also concerned about the requirement that medical staff must undertake a detailed discussion with a patient who may be undergoing a psychiatric episode while attempting to secure an oral and written consent to use anti-psychotic drugs. While there are better ways to address inappropriate use of such drugs, adding an additional paperwork burden that delays care and puts healthcare staff at risk of injury raises significant public safety concerns. We would welcome the opportunity to work with the committee on alternative approaches to the issue. For instance, focus could be placed on value-added quality improvement processes to monitor the use of anti-psychotic medications in certain facilities, including hospitals, and if reporting demonstrates overutilization or overreliance on such medications in specific locations, steps could be taken to work with such providers to revise or implement best practices on the appropriate use of such medications. The legislature specifically provided such a process when it enacted section 140 of Ch. 165 of the Acts of 2014 (the FY15 budget) which took effect on January 1, 2015. This law requires nursing homes, rest homes and other long-term care facilities to obtain informed written consent of residents, their healthcare proxies or their legal guardians prior to administering psychotropic medications. Data highlighting the overutilization of anti-psychotics in these facilities spurred the need for this legislative action. In enacting the law, the legislature rightfully refrained from extending its provisions to hospitals and recognized the inherent differences between long-term care facilities and hospitals in professional protocols, trained medical staff, and emergent circumstances.

MHA is opposed to SB1248. As drafted, this legislation poses significant administrative burdens and conflicts and could unintentionally reduce the value of the information that is already provided to patients and families. SB1248 requires healthcare providers to provide patients with detailed information sheets that outline the use and side effects of any medications that are administered to a patient, along with a written acknowledgment from the patient that the form was received. While we understand that the goal of this bill is to provide information on the care and treatment received in a hospital, MHA is very concerned about the practical consequences that SB1248 would require. At the beginning of an individual’s stay in a facility, he or she completes paperwork and signs multiple forms, including an informed consent form that stipulates that the patient will be receiving various treatments for their condition. Upon discharge, the patient also receives additional paperwork that outlines the care provided to the patient and instructions as to what the patient should be doing for follow-up services to ensure that they do not relapse. In addition to these procedures, SB1248 would introduce additional responsibilities and require the creation of several additional individual patient forms, substantially increasing the number of forms to be completed per patient, to outline the medications received and the various risks associated with such medications. Given the amount of differing medications that a person receives when in the hospital and based on the acuity of their illness, SB1248 would require numerous documents (each document being several pages long) for each medication administered. Hospitals would require additional staff to track the development and acknowledgment of these forms for each patient, as well as maintain copies of these forms to be included in the patient’s medical record. The amount of paperwork that a patient receives today in a healthcare facility is quite extensive, and SB1248 would multiply this paperwork by such a large number that it would inhibit the value of all of these forms. While MHA appreciates the intent and sentiment behind this legislation, we believe SB1248 would substantially increase the costs and administrative time for patients and providers that would hinder appropriate patient care.

MHA is strongly opposed to SB1270, which would add increased costs and operational constraints without any benefit to improving access to care. SB1270 establishes additional oversight and review of essential service closures to provide for both a DPH and a judicial approach to preventing a closure. Similar to our comments to SB1269, this legislation would only put into place additional bureaucratic requirements without taking into consideration the reasons that a hospital must consider a closure of an essential service. While no hospital wants to close any service, they are faced with the constant challenge of remaining financially viable and operationally sound in an environment of increasing government underpayments; shortages of critical caregivers; rising labor costs; a growing elderly population; and the need to continually reinvest in people, aging physical plants, and technology. Hospitals constantly balance the needs of the communities they serve with the resources available to support essential services. The Center for Health Information and Analysis already reviews and publicly posts hospital financial information and considers the key environmental factors/challenges that affect the ability of hospitals to continue to provide services. Other state agencies are also conducting similar operational and community access to care reviews. Adding a new layer of reviews and oversight onto a system that is struggling to meet continued and costly operational challenges would be counter-productive. One of the largest problems that providers are facing is the lack of support on key services such as behavioral health and primary care services. No hospital wants to close needed services. However, many providers are forced to consider the reduction or elimination of behavioral health and primary care services because state funding and resources for these services are alarmingly insufficient. The drastic inequities for these services place an enormous drain on other necessary services hospitals must offer to their communities. Hospitals cannot continue to fund services and provide emergency care (which is one of the most essential services to a community) with the continued lack of funding and resources from the state. Without focusing on the systemic issues that are impacting providers, SB1270 ignores the chance to address the fundamental causes that are associated with the closure of a unit or certain services.

MHA opposes HB1175, which would create a duplicative governance and oversight of hospital specific policies, thereby negating the role of a hospital Board of Trustees. As proposed, HB1175 will add a layer of cost and duplicative administrative functions on hospitals and increase the overall costs of the commonwealth’s healthcare system without any demonstrable benefit. Essentially, HB1175 proposes that each medical staff should be an autonomous entity within a hospital. This includes adding a layer of administrative oversight, legal review, and the development of quality reporting and initiatives inherent to the medical staff only. If there were specific clinical and clinician concerns that were identified by the hospital at any time, then under HB1175, the hospital medical staff can use their own process to negate any concerns or hospital policies to require increased patient safety standards. In addition, at a time when the state and federal governments are developing rules for accountable care organizations that seek to coordinate care across a continuum, HB1175 will actually limit the ability of such organizations to develop integrated models of care if they have to abide by different governing policies and practices. Healthcare stakeholders are currently working collaboratively on the development of uniform and nationally based quality measures for reporting by the entire healthcare entity. Under HB1175, hospitals and their medical staffs would be required to develop separate reporting and quality initiatives that may not be aligned and, as a result, would be in direct violation of federal and state reporting standards. If the intent of HB1175 is to address those situations where medical staff and hospitals boards are in conflict, such resolutions should occur through an internal review process that strengthens the institution as a whole and does not create the additional levels of bureaucracy and costs proposed by HB1175.

MHA is opposed to HB1197, which would require a healthcare facility to obtain a new licensure status for any secondary facility that it operates. Both Congress, through the Affordable Care Act, and this legislature, through Chapter 224, are incenting healthcare providers to be more creative in developing integrated care organizations, global billing, and/or integrated networks to help lower the cost of care. In addition, federal laws and regulations permit providers to develop centralized systems of care that have multiple locations to help eliminate duplicative and unnecessary administrative procedures as well as assisting patients in quickly and efficiently moving through the healthcare continuum. HB1197 would limit the movement that policymakers have urged the healthcare system to adopt and potentially prevent facilities or entities from joining an integrated system or network of care. Having to develop separate licensed facilities would require duplicative contracts, billing systems, and clinical practices at each site, instead of coordinating all of these services through one centralized and coordinated system. For these reasons MHA strongly opposes HB1197.

MHA opposes SB1230 which would impose new penalties on healthcare providers for a variety of potential actions. This bill is misdirected and poses significant implications to the access and provision of care regardless of the circumstances. It would be improper to legislate on such a basis and certainly to impose penalties without further investigation that examines the facts, circumstances, and consequences of the underlying actions. SB1230 would inappropriately restrict the ability of all healthcare providers (defined to include hospitals, nursing homes, home healthcare, physician offices, community health centers, assisted living facilities, among others) from appropriately caring for patients. It would prevent patients who choose to self-pay for services to seek care and treatment through specialized programs. While we agree that no patient should be treated differently due to their ability to pay, we also agree that patients should not be prevented from seeking care if they are able to afford to pay privately for services. In particular, for many patients who are seeking post-acute and other long-term care services (such as personal care attendant or elder care services), SB1230 would prevent patients from seeking additional care if they are able to privately pay for care that is not covered by insurance or other coverage options. This proposal deserves to be subjected to a full legislative or regulatory process where appropriate review and input can be offered in a manner to best protect against unintended consequences. Among the unintended consequences, SB1230 would impede the gathering of data on sociodemographic status (SDS) of patients. Research has demonstrated that SDS status affects healthcare outcomes, performance metrics, and quality of care. In order to broaden and deepen the scope of such research, with the ultimate goal of refining provider quality performance metrics and re-directing resources to the most vulnerable patients in society and to the providers that care for them, it is critical that detailed, granular, and nuanced information continue to be available in claims databases.

MHA strongly opposes HB2441, which prohibits the use of system-level contracting. At the outset it is important to note that this proposal was rejected by the legislature as a proposed provision of Chapter 224 when the law was constructed. Any requirement forcing separate facility contracting is a direct and unprecedented government intervention -- not only into private contract negotiations -- but also into the regulation of corporate entities. There is no other example of such drastic state government intrusion. Furthermore, HB2441 places hospitals in an untenable position when they negotiate with insurers. There are four major private insurers that cover 80 percent of the state’s population – all with significant market leverage to dominate negotiations with the majority of hospitals. Some systems may merely be a couple of small community hospitals. If the legislature imposes such restrictions on hospital systems, it will be deciding to employ government power to ensure that virtually no hospital in the state has the means to negotiate fairly with major insurers. A system contracting restriction, such as that proposed in HB2441, also runs counter to the purpose of the federal ACA and state healthcare reform laws, both of which are focused on increasing coordination of care and collaboration among providers to produce better care and cost savings. In fact, it is neither feasible nor fair to ask a system that shares clinical, facility, Health Information Technology, and personnel resources to artificially disintegrate those resources for contract negotiations or to develop dual negotiation systems in many instances. Hospitals developed systems in order to cooperate among entities within the system and to create more efficient operating and clinical programs within the system, not to have those entities rip apart those programs because of a legislative mandate. HB2441 will only result in significant and unwarranted increase in administrative and clinical costs -- which runs counter to the legislature’s stated intent to lower healthcare costs. Contract negotiations are often long, complex and labor intensive processes. Allowing insurers to centralize all their resources for negotiating purposes while forcing hospitals to dismantle their resources will undoubtedly be a welcome development for the insurance industry, but it will be an unwelcome development for those who care about sensible and sound public policy. Increasing the number of negotiations for healthcare systems, by payer, runs counter to the goals of both federal and state health care reform legislation.

MHA strongly opposes HB2477, which seeks to allow for parties (including lawyers and the general public) to seek access to peer review materials. The purpose of medical peer review is to provide a confidential process for identifying, tracking, and resolving clinical performance and medical errors in their early stages. Through a confidential forum, providers can be examined and the facility can develop a process to change clinical practices and improve the delivery of care to patients. HB2477 would inappropriately allow any outside party to seek a copy of the proceedings for future judicial or administrative procedures. This would negate the confidential process that has been adopted nationally and potentially prevent many providers from requesting a confidential review of services to determine what improvements can be made to a clinical practice. MHA and our members strongly oppose HB2477.

MHA is also opposed to HB3514. MHA is very concerned that this bill that would require a physician to be present from the moment of the incision to the final skin closure of the surgical site. It is standard practice that once a procedure is completed and there is another physician or surgical resident who is available to complete the final closure, then the attending physician may leave to discuss the case with the patient’s family or undertake final tasks in the operating room that do not necessarily require the actual closure of the skin. In many teaching hospitals, it is a national standard to allow another provider to assist with and complete certain procedures. MHA is concerned with the unintended problems that this legislation may cause, including delaying the provider from discussing procedures until a simple procedure such as the skin closure is completed. If there are patient safety concerns that have arisen due to concurrent surgical procedures, any regulatory actions that may be undertaken should follow evidence-based medical standards of practice put forward by professional organizations with expertise in this area. For these reasons we are opposed to

While MHA supports the general concepts within SB1212, the bill would actually be contrary to the plans of the Executive Office of Health and Human Services to adopt updated regulations on psychiatric hospitals and psychiatric units of acute care hospitals. These regulations would specifically require a facility to consider the needs of the commonwealth and of each patient prior to denying the admission of any patient with a mental health condition who needs inpatient placement. SB1212 would require that a hospital have an agreement with an inpatient provider to ensure that beds are available for placement of patients. The bill would also require that a facility must hold their beds for patients seeking placement from their contracted or affiliated acute care hospitals. SB1212 would go against the goals of EOHHS, which is to develop a statewide approach to ensuring that all patients are able to access any licensed psychiatric bed regardless of the location and the hospital affiliation. While we again support the concept, we are concerned with the unnecessary confusion between this bill and the new EOHHS regulations. For these reasons we oppose SB1212 as drafted.

MHA is strongly opposed to SB1234, which would require the development of a duplicative patient rights notice for those patients who are placed into an observation status. Effective March 8, 2017, all hospitals with an inpatient unit and which are a Medicare provider are already required under federal law to adopt internal policies and practices for informing a patient when they are placed in an observation unit and to further communicate to the patient the impact that such placement may have on post-discharge level of care placements. MHA, working with our members have adopted uniform and standard notices to ensure compliance with federal law. For these reasons, SB1234 does not have any merit and, if enacted, would be struck down as being pre-empted by federal law. We would urge this committee to not create an unnecessary complication and confusion for patients and the provider community in trying to pass an unnecessary state law.

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