June 4, 2020
The Honorable Teresa D. Miller
Pennsylvania Department of Human Services
333 Health and Welfare Building
Harrisburg, PA 17110
Dear Secretary Miller:
Thank you for your time and participation during our call with Commissioner Altman and the private payor community during early May.
Our discussion briefly touched upon two very important topics related to delivering health care services during both the pre- and post-COVID-19 environment—hospital post-acute placements and telemedicine.
We thought it might be helpful to share some additional information about the opportunities and challenges hospitals are and will continue to be face in the near future.
Post-Acute Treatment Crisis: Hospitals experience significant difficulties finding appropriate post-acute placements—which has severe negative consequences for patient care and financial implications for hospitals. As you heard during our meeting, these difficulties have become even more acute during the COVID-19 crisis.
Prolonged and unnecessary hospital stays have a range of effects upon patients, including increased dependency, loss of confidence in their ability to cope, depression, risk of infection, and other adverse consequences. Prolonged stays also make long-term institutionalization more likely. From a system perspective, delays in discharge negatively affect the efficient use of health care resources and cause other patients to wait longer for care elsewhere within the system.
HAP staff had been working collaboratively with the Pennsylvania Department of Human Services (DHS) (specifically Ms. Leesa Allen, Ms. Val Vicari, as well as representatives from the Office of Long-term Living [OLTL]) to facilitate placements for patients who require behavioral health treatment and establish a process to allow hospitals to elevate problematic cases to DHS. As you can imagine, these discussions were hampered with the onset of COVID-19, but we are very interested in re-engaging in discussions. Also, HAP has been advocating for behavioral health access, which culminated in a Joint State Government Commission (JSGC) effort to perform a behavioral health access study. The report, which likely will be released this month, will evaluate the patient care impact of delayed discharges of patients with behavioral health diagnoses.
While we were initially focused on challenges related to finding placements for patients with behavioral health needs, delays also are caused by factors other than insufficient behavioral health capacity. During a 2016 survey, 65 of 70 Pennsylvania hospitals (93%) were unable to find timely placement for patients who required long-term care following an emergency department admission. Nearly 50 percent reported that treatment delays occurred more than ten times per year. Other hospitals report that insufficient funding for personal care homes is a contributing factor for low-income citizens who do not need nursing home or medical care.
Following our recent meeting, we reached out to solicit specific examples to share with you, per your request, and have provided them in the attached document.
One of our last conversations with Ms. Vicari indicated that DHS was in the final stages of drafting an escalation policy that would enable hospitals to engage counties, behavioral health- HealthChoices managed care organizations, and DHS when a difficult placement situation is occurring and this would be shared with us to review. We currently are following up with the Office of Mental Health and Substance Abuse Services (OMHSAS) about this issue, and plan to engage the OLTL regarding the development of a similar policy within Community HealthChoices. We ask for your support in these efforts.
Telemedicine Advancements: COVID-19 has accelerated the use of telemedicine unlike any other recent event. As you mentioned during our discussion, this progress should not be squandered. Telemedicine will continue to be a vital means of service delivery, one that likely to be demanded by health care consumers. While we certainly expect that the health care delivery system will return to some type of new normalcy, our patients likely will be less willing to engage in in-person care for services they were able to receive within the safety of their own homes just weeks before.
Ensuring that we continue to provide an environment that allows health care practitioners to meet their patients’ needs will require continuing many of the provisions that were created for the COVID-19 situation. Examples include allowing for telephonic visits in the event that a patient does not have the means to connect via video, paying for the service at the same rate that would be paid for a similar in-person visit, and continuing to allow for non-traditional telemedicine platforms.
We strongly urge DHS to continue these policies following the COVID-19 crisis to address patient concerns and maintain access to care.
Before turning to next steps, I would like to address the statement made by Sam Marshall during our meeting that it was inappropriate and/or impermissible under antitrust laws for meeting participants to discuss prior authorization practices. This assertion is incorrect. Under what is known in antitrust law as the Noerr-Pennington doctrine, it is entirely permissible for industry groups to discuss policy issues and seek to influence regulatory action before government officials. Our discussions were focused entirely upon steps the government could take to help the health care delivery system address COVID-19, and there is no reasonable basis to think the conversation could have an anti-competitive effect.
Next Steps: As a next step, HAP plans to continue to follow up individually with the relevant program offices to address these issues. However, we believe it would be useful to meet with you and your team within the next several weeks to assess the status of these efforts and discuss how we can continue to work together to ensure access to care for Pennsylvania’s Medical Assistance enrollees. To facilitate this meeting, I will ask my assistant, Dan Smedley, to reach out to your office to find an acceptable time.
Please feel free to contact me with any questions, and thank you for your interest in addressing these important issues.
President and Chief Executive Officer
cc: Jessica K. Altman, Commissioner