Fact Sheets https://www.aha.org/ en No Surprises Act Implementation Handbook https://www.aha.org/2021-09-14-no-surprises-act-implementation-guide <span class="title">No Surprises Act Implementation Handbook </span> <span class="uid"><span>cdailey_drupal</span></span> <span class="created">Sep 14, 2021 - 10:55 AM</span> <div class="body"><p><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">The No Surprises Act established new patient protections against balance billing in certain circumstances, as well as put into place a number of other provisions that will change how providers and health plans engage with patients and each other with respect to price and coverage transparency, as well as billing. The following implementation guide is intended to help hospitals and health systems understand the new provisions in the law and corresponding regulations. The following sections provide:</span></span></span></p> <ul> <li style="margin-left:11px"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">A summary of the various provision,</span></span></span></li> <li style="margin-left:11px"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">The effective date</span></span></span></li> <li style="margin-left:11px"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">Links to the legislation, regulatory text, and additional federal guidance when available</span></span></span></li> <li style="margin-left:11px"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">Frequently Asked Questions</span></span></span></li> </ul> <p><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="color:#1f497d">This implementation guide is a living document and will be updated as the government releases additional information and as the AHA obtains answers to outstanding questions. Please check back frequently for updates. We will note in the text when an FAQ is new or updated. </span></span></span></p> <p>&nbsp;</p> <div class="container row"> <div class="row"> <div class="col-md-12"> <div class="col-md-12 cc_tabs"> <style type="text/css">/* reset */ .cc_tabs ul.a-container { margin: 0; padding: 0; list-style: none; } .cc_tabs input[type=checkbox] { display: none; } /* style */ .cc_tabs .a-container { width: 100%; margin: 20px auto; } .cc_tabs .a-container label { display: block; position: relative; cursor: pointer; font-size: 18px; font-weight: bold; padding: 10px 20px; color: #63666a; background-color: #eee; border-bottom: 1px solid #ddd; -webkit-transition: all .2s ease; -moz-transition: all .2s ease; -ms-transition: all .2s ease; -o-transition: all .2s ease; transition: all .2s ease; margin-bottom:15px } .cc_tabs .a-container label:after { content: ""; width: 0; height: 0; border-top: 8px solid #aaa; border-right: 6px solid transparent; border-bottom: 8px solid transparent; border-left: 6px solid transparent; position: absolute; right: 10px; top: 16px; } .cc_tabs .a-container input:checked + label, .cc_tabs .a-container label:hover { background-color: #003087; color: #fff; } .cc_tabs .a-container input:checked + label:after { border-top: 8px solid transparent; border-right: 6px solid transparent; border-bottom: 8px solid #fff; border-left: 6px solid transparent; top: 6px; } .cc_tabs .a-content { padding: 0 20px 20px; display: none; height:auto; max-height: 40vh; overflow: auto } .cc_tabs .a-container input:checked ~ .a-content { display: block; } </style> <style type="text/css">/* Style the tab */ .cc_tabs .tab { background-color: #fff; width: auto; height: auto; overflow: auto; } /* Style the buttons inside the tab */ .cc_tabs .tab button { display: block; background-color: lightgry; color: #003087; padding: 10px 16px 10px 20px; width: calc(50% - 30px); border: solid 1px lightgray; outline: none; text-align: center; cursor: pointer; transition: 0.3s; font-size: 20px; float: left; overflow: auto; margin: 0px 15px; -webkit-border-top-left-radius: 15px; -webkit-border-top-right-radius: 15px; -moz-border-radius-topleft: 15px; -moz-border-radius-topright: 15px; border-top-left-radius: 15px; border-top-right-radius: 15px; font-weight: 700; } @media (max-width:452px){ .cc_tabs .tab button{ padding: 10px 5px 10px 5px; width: calc(50% - 4px); font-size: 17px; margin: 0px 2px; } } /* Change background color of buttons on hover */ .cc_tabs .tab button:hover { background-color: #003087; color:#fff } /* Create an active/current "tab button" class */ .cc_tabs .tab button.active { background-color: #003087; color: #ffffff } /* Style the tab content */ .cc_tabs .tab .tabcontent { float: left; padding: 15px 12px; border: 1px solid #ccc; width: 100%; height: auto; } .cc_tabs .tablinks:after { content: '\2610'; color: #777; font-weight: bold; float: right; margin-left: 5px; } .cc_tabs .tablinks.active:after { content: "\2611"; } </style> <!-- <div class="tab"><button class="tablinks" id="defaultOpen" onclick="openCity(event, 'Certified')">Get Certified</button><button class="tablinks" onclick="openCity(event, 'Recertify')">Recertify</button></div> --> <div class="tabcontent" id="General"> <ul class="a-container"><!-- item01 --> <li class="a-items"><input id="z1" name="ac" type="checkbox" /> <label for="z1"> Protections against Balance Billing for Certain Out-of-network Care</label> <div class="a-content"> <p><b>What It Is: </b>Health care providers, including both professionals and facilities, will not be permitted to bill<b> </b>out-of-network patients for more than their in-network cost-sharing amount for certain services. These include:</p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Emergency services, including any services provided post-stabilization</b> until the patient is discharged or transferred. In some instances, the provider and/or facility may seek the patient’s consent to balance bill for the post-stabilization services. See the section on “notice and consent” for more information.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Scheduled professional services</b> when provided at an in-network facility unless the provider obtains the patient’s consent. For limits on which providers are eligible to seek consent, please see the section on “notice and consent.” </span></span></span></li> </ul> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Assessing Patient Cost-sharing for Out-of-network Services:</b> Insurers must inform providers about the correct cost-sharing amount. While it is possible that the plan may provide the accurate cost-sharing amount when the provider runs an eligibility check, it is much more likely that the provider will need to first bill the plan in order to receive an adjudicated claim with the correct cost-sharing amount. The provider may then bill the patient the amount identified by the plan.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> January 1, 2022</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Potential Penalty for Violations: </b>Providers face up to $10,000 in civil monetary penalties<b> </b>for each violation. States have primary responsibility for ensuring compliance. However, the federal government may investigate potential violations and issue penalties in some instances.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> <ul style="list-style-type:circle"> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 102. Health insurance requirements regarding surprise medical billing. </span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 104. Health care provider requirements regarding surprise medical billing. </span></span></span></li> </ul> </li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: </b>See the following sections of the Code of Federal Regulations, as discussed in the <a href="https://www.govinfo.gov/content/pkg/FR-2021-07-13/pdf/2021-14379.pdf" style="color:#0563c1; text-decoration:underline">Interim Final Rule: Requirements Related to Surprise Billing; Part I </a></span></span></span> <ul style="list-style-type:circle"> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>ERISA: </b>29 CFR Part 2590<b> </b></span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Individual and Fully Insured Markets: </b>45 CFR 147, 45 CFR 149</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Federal Employee Health Benefit Plans:</b> 5 CFR 890.114</span></span></span></li> </ul> </li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance: </b>N/A</span></span></span></li> </ul> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions</b></span></span></span></p> <ol> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How will I know if a patient is subject to these protections?</b> We continue to have substantial concerns regarding when a provider will know if a patient is subject to the balance billing protections. We are encouraging the federal government to require that health plans provide that information to the provider at the point an eligibility determination is done. However, this will require the creation of a new field and/or modifier. In the meantime, we encourage providers to err on the side of caution when sending bills to patients for out-of-network care, which may mean waiting until the claim is adjudicated before attempting to collect any cost-sharing.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Can patients still choose to go out-of-network and pay out-of-pocket?</b> Yes (in some instances). Patients can continue to intentionally seek care from out-of-network providers and may be subject to the cost of that care at their own expense. However, in some instances, an out-of-network provider may not be permitted to balance bill the patient. For example, some providers, such as assistant surgeons, anesthesiologists, and radiologists may not bill the patient directly. These providers may elect not to provide care to out-of-network patients or they may accept payment from the plan, subject to the remedies established under the law if a disagreement emerges over reimbursement.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How much do I bill the patient?</b> Providers will need to bill the patient’s health plan before learning definitively the amount to bill the patient.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>My state has a surprise billing law. How will I know whether the state or federal law applies?</b> Whether state or federal law (or both) apply depends on the circumstances of the case. Generally, state law applies to state-regulated products (e.g., fully insured individual and group market), and federal law applies to products that are primarily regulated at the federal level (e.g., self-insured/ERISA, FEHBP). However, in some states, a federally-regulated plan may opt into the state process. In addition, if the state law is less protective than the federal law, the federal law may “wrap around” the state law to provide comprehensive protection. An example of this is when a patients receives both emergency and post-stabilization services and the state law only provides protections for the emergency services. In that instance, the state law protections apply for the emergency services, and the federal law applies to the remainder of the care (up to the limits in federal law and regulations).</span></span></span><br /> <br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The AHA is very concerned that the question of which law applies may be extremely difficult for providers to know. We are urging the federal government to clarify that the patient’s health plan must specify which law applies as part of the eligibility transaction, as well as part of the final claims adjudication. We believe plans will have a better understand of which law applies as they know the type of health plan the patient has. </span></span></span></li> </ol> <p>&nbsp;</p> <ul> </ul> </div> </li> <!-- item02 --> <li class="a-items"><input id="z2" name="ac" type="checkbox" /> <label for="z2"> Independent Dispute Resolution Process</label> <div class="a-content"> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What It Is: </b>Reimbursement for out-of-network services may be determined in one of several ways. The legislation defers to state law or policy if applicable. If no such policy applies, then the legislation defines the process through which reimbursement is determined. First, the provider may accept the initial payment made by the plan. Second, the health plan and provider may come to a mutually agreeable amount through routine negotiating procedures during a 30-day period beginning the day the provider receives the initial payment (or payment denial) from the plan. Finally, should either of these fail, the parties may bring an outstanding dispute to an independent dispute resolution (IDR) process established under the law. However, the parties can continue to negotiate during the IDR process and do not need to complete it if they can agree to reimbursement during this period. </span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>IDR Timeline:</b> If a provider and health plan cannot come to agreement on reimbursement within 30 days of the initial payment from the plan to the provider, either party may trigger the IDR process (referred to as “notifying”) within four days of the conclusion of the 30-day open negotiation period. The plan and provider then have three business days to jointly select the IDR entity to oversee the case; should that fail, the HHS Secretary has up to three business days to select one on their behalf. Within 10 days of the selection of the IDR entity, each party must submit an offer for reimbursement, as well as any supporting materials. The IDR entity must select one of the offers without modification as the final reimbursement determination within 30 days of the IDR entity having been selected. Once a determination has been reached in a case, the payer must remit reimbursement to the provider within 30 days. </span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The party that submitted the notification to initiate the IDR process may not submit another case for the same item or service involving the same other party during a 90-day period after the initial notification. This is frequently referred to as a “cooling off” period. However, the party may hold such claims and then submit them for IDR within the four-day period after the 90-day “cooling off” period is over. The statute provides the HHS Secretary with significant discretion to modify the timelines applicable to these provisions.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>IDR Entity Factors for Consideration: </b>IDR entities are directed to consider a number of factors when making their payment selection, including the qualifying payment amount for the applicable item or service (see above) and, at either the request of the IDR entity or as part of voluntary submission by the plan or provider, information on: the level of training, experience, quality and outcomes of the provider; the market share held by the provider and/or the plan; patient acuity; teaching status, case mix, and scope of services of the provider; demonstrations of good faith efforts to enter into a network agreement with the other party; and, if applicable, past contracted rates between the parties during the previous four years. IDR entities may not consider provider charges or rates paid by public programs, such as Medicare, Medicaid, the Children’s Health Insurance Program or TRICARE.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Batching of Items and Services.</b> Providers may batch together like claims attributable to the same health plan that occur during a 30-day period. However, the Secretaries, via regulation, will provide additional details on the criteria for such claims and may, according to the statute, modify the timeframe for batching.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Fees.</b> The party that submits the losing bid is responsible for the costs of the IDR process unless the dispute is resolved between the two parties prior to the conclusion of the process. In that case, the parties split whatever costs have been incurred by the IDR entity to that point. The statute also references administrative fees to be paid to HHS by both parties; however, it is unclear at this time whether those fees are separate from what is paid to the IDR entity and whether the losing party must pay those fees as well.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Public Posting of Information.</b> The HHS Secretary must post publicly certain information about the IDR process on a quarterly basis, and the IDR entities are required to provide this information to the HHS Secretary for this purpose. Beginning in 2022, the HHS Secretary must post information on: the number of requests for IDR (“notifications”); the size of the provider practices or facilities submitting notifications; the number of cases that resulted in the IDR making a determination (versus being settled between the two parties); a description of the item or service at issue; where (geographically) the item or service was delivered; the amount each party offered through the IDR process; which offer was selected; the identity of the parties; the category and practice specialty of the provider or facility; the length of time it took the IDR entity to make a determination; the compensation paid to the IDR entity; the amount HHS has expended to carry out the IDR process; and other information as specified by the HHS Secretary. The statute does limit the HHS Secretary from posting certain privileged or confidential information.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Selection of IDR Entities.</b> The statute outlines several eligibility criteria for IDR entities but directs the Secretaries of HHS, Labor, and Treasury to establish a process for certification through regulation. The law requires that the IDR entities have relevant medical and legal expertise, as well as sufficient staffing to make determinations on a timely basis. The organization cannot be biased, e.g., a health plan, provider, or association of either plans or providers, and must meet other requirements, including certain fiscal integrity and confidentiality requirements. The Secretaries shall ensure that a sufficient number of entities are chosen to ensure timely determinations, and entities will be certified for a 5-year period, subject to revocation for noncompliance with any requirements.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> January 1, 2022</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> <ul style="list-style-type:circle"> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 103. Determination of out-of-network rates to be paid by health plans; Independent dispute resolution process.</span></span></span></li> </ul> </li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: </b>N/A</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance: </b>N/A</span></span></span></li> </ul> <p style="margin-left:8px">&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions</b></span></span></span></p> <ol> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What kind of information can I bring to the IDR process to make my case?</b> While we are awaiting additional federal guidance, the law establishes </span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>&nbsp;How do I initiate the IDR process? </b>Awaiting further guidance.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How do I pick an IDR entity?</b> Awaiting further guidance.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What kinds of claims can be batched together?</b> Awaiting further guidance.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Any advice on how I should evaluate claims for whether to take them to the IDR process?</b> The AHA anticipates providing member hospital and health systems with insights into whether and when to use the IDR process. However, we must first better understand the rules of the process.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>My state law provides protection for patients against balance billing but does not include any approach for addressing reimbursement disputes between plans and providers. For applicable state-regulated plans, would the state law apply for purposes of patient protection and the federal law apply for purposes of reimbursement or would one prevail entirely?</b> Yes. That is currently how the regulations intend for state laws and the federal laws to work. The state law applies first, and the federal law “wraps around” the state law if gaps remain.</span></span></span></li> </ol> <p>&nbsp;</p> <p>&nbsp;</p> <ul> </ul> </div> </li> <!-- item03 --> <li class="a-items"><input id="z3" name="ac" type="checkbox" /> <label for="z3"> Qualifying Payment Amount</label> <div class="a-content"> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What It Is: </b>The No Surprises Act established a calculation referred to as the “qualifying payment amount” (QPA) for two purposes: 1) to determine patient cost-sharing, and 2) as a factor for consideration by the arbiter as part of the independent dispute resolution process.</span></span></span></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The statute defines the QPA as the plan or issuer’s median in-network rate for the same or similar item or service that is provided by a provider in the same or similar specialty and in the same geographic region in 2019 trended forward. In the case of a self-insured group health plan, the administering entity is treated as the plan for purposes of these provisions. The departments establish an approach for calculating the QPA when insufficient information exists, such as when a plan is new and did not contract with providers in 2019 or the item or service is new.</span></span></span></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The first set of interim final regulations adopt the following methodology for calculating the QPA.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Methodology for Calculation: </b>The regulations require that the median contracted rate be calculated by arranging in order from least to greatest the contracted rates of all plans of the plan sponsor (or of the administering entity, if applicable) or all coverage offered by the issuer in the same insurance market that meet the above criteria, and selecting the middle number. In cases of an even number of rates, the plan or issuer must average the two middle numbers. There must be at least three rates for purposes of this calculation.</span></span></span></p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The regulations establish the following definitions for purposes of calculating the QPA:</span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Contracted Rate. </b>The contracted rate is the total amount (included cost-sharing) that a plan or issuer has contractually agreed to pay a provider, including through a third-party administrator or pharmacy benefit manager. If the plan or issuer has multiple contracts with a provider and each have a different rate, each rate is counted separately for purposes of calculating the QPA. Rates from rented networks and arrangements with third-party entities to administer certain benefits also count as the plan’s or issuer’s rates for purposes of the calculation. However, rates associated with single case agreements, letters of agreement, or other similar arrangements between providers and plans/issuers do not count; according to the departments, such rates may not reflect market rates of “typical” contract negotiations.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Insurance Market. </b>Plans and issuers may only use rates from plans within the same insurance market. For purposes of the QPA calculation, this means: the individual market, small group market, or large group market. With respect to self-insured plans, the regulations define the term to mean all self-insured group health plans of the plan sponsor or, at the option of the plan sponsor, all self-insured group health plans administered by the same entity, e.g., a third party administrator. Medicare and Medicaid rates, regardless of whether they are administered by a managed care entity, are excluded from consideration. Similarly, rates for short-term, limited duration, account-based plans, and other forms of limited coverage are not included in the definition of applicable insurance.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Same or Similar Item or Service. </b>The regulations define “same or similar item or service” as a health care item or service billed under the same service code, or a comparable code under a different procedural code system, such as the Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Diagnosis-Related Group (DRG) coding systems. The departments note that the plans and issuers must take into account modifiers that affect payment rates, as well as calculate separate median contracted rates for providers and facilities.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Provider in the Same or Similar Specialty. </b>The regulations define “provider in the same or similar specialty” as the practice specialty of a provider. Plans/issuers only have to take into account the provider specialty if they contract for a service at different rates based on the provider’s specialty. In these instances, the plan must identify the provider’s specialty consistent with the plan’s or issuer’s usual business practice and then calculate separate QPAs by specialty. Similarly, if the plan does not vary the contracted rate by provider specialty, it does not need to calculate separate QPAs by specialty. For purposes of air ambulance services, all providers are considered to be a single provider specialty regardless of any variation in type of air craft or whether the air ambulance is hospital-based or independent.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Facility of the Same or Similar Facility Type. </b>The regulations distinguish only two types of facilities: hospital-based emergency departments and independent freestanding emergency departments. In other words, in instances where the plan or issuer contracts at different rates for emergency services based on the type of facility, it must calculate separate QPAs for those services. Otherwise, the regulations do not permit plans and issuers to account for other facility characteristics when determining which rates to use in the calculation. The regulations specifically give as an example academic medical centers and teaching hospitals and state that they do not believe patients should incur higher cost-sharing for emergency services because some types of facilities have different characteristics that may result in higher contracted rates.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Geographic Regions. </b>Plans and issuers must only include rates from within the same geographic region. For purposes of the calculation, each metropolitan statistical area (MSA) in a state constitutes its own region, with all other portions of the state combined to form a single region. If a plan or issuer does not have sufficient contracted rates in a given MSA, the plan/issuer must consider all MSAs in the state as one region. If this approach still does not provide enough data points, the plan or issuer must calculate the QPA based on all MSAs in the appropriate Census division and one region consisting of all other portions of the Census divisions. For air ambulances, the region is determined based on where the patient was picked up. In addition, for air ambulances, the geographic regions are determined at the state level (all MSAs together as a single region with all other areas of the state as another region), escalating to the Census division if necessary.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Non-Fee-for-Service Contractual Arrangements. </b>The regulations address how to determine the rate for contracts that are based on bundled payment, capitation, or other forms of non-fee-for-service arrangements. The regulations direct issuers to use the internal, underlying fee schedule amount. They note that plans and issuers often use an underlying fee schedule to calculate patient cost-sharing or for other purposes, such as compliance with the transparency in coverage regulations. If such an underlying fee schedule does not exist, the plan or issuer must use a derived amount, which is the price that a plan or issuer assigns an item or service for purposes of internal accounting, reconciliation with providers, or for submitting required data to regulators. This is the same approach that plans and issuers must use in similar circumstances for purposes of implementing the transparency in coverage regulations.</span></span></span><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The regulations also specify that plans and issuers must exclude risk sharing, bonus/penalty, and other incentive-based and retrospective payments or payment adjustments, which they believe is consistent with how patient cost-sharing is typically determined in in-network scenarios when providers are reimbursed under value-based arrangements.</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Special Rules for Unit-based Services. </b>The departments note that for some services plans and issues may determine reimbursement by multiplying the contracted rate by another unit, such as time or mileage; the regulations therefore require that plans and issuers apply these multipliers after identifying the median contracted rate for the base unit. The regulations also specifically address anesthesia and air ambulance services.</span></span></span></li> </ul> <ul> <li style="list-style-type:none"> <ul style="list-style-type:circle"> <li style="margin-left:16px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Anesthesia. </b>Anesthesia services are<b> </b>generally reimbursed based on a combination of a negotiated base rate that is then adjusted by the number of units used, time and the physical status of the patient. Plans and issuers must first calculate the median contracted rate for the anesthesia conversion factor for the same or similar item or service (trended forward as appropriate) and then apply the necessary modifiers to reflect the base units, time units and physical status modifier units.</span></span></span></li> </ul> </li> <li style="list-style-type:none"> <ul style="list-style-type:circle"> <li style="margin-left:16px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Air Ambulance. </b>Plans and issuers generally reimburse air ambulance services based on a<b> </b>base rate for the air ambulance service code multiplied by the number of miles while the patient is onboard (“loaded”). To calculate the QPA for air ambulance services, the plans and issuers must first calculate the median contracted amount for the air mileage service code (trended forward as appropriate) and then multiply it by the number or loaded miles.</span></span></span></li> </ul> </li> </ul> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Indexing. </b>The QPA for 2022 is the 2019 QPA trended forward by the consumer price index for all urban consumers (CPI-U), and will be indexed to CPI-U in perpetuity. The regulation provides specifications for calculating the index rate annually. In order to ensure uniformity, plans and issuers will calculate the increases using factors determined by the Treasury Department and the IRS, and published in guidance by the IRS.</span></span></span></li> </ul> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Cases with Insufficient Data:</b> Plans and issuers must have at least three contracted rates on Jan. 31, 2019 to calculate the QPA. The regulations lay out alternative processes for determining the QPA in instances where the plan or issuer does not have sufficient data from 2019, including in instances where the item or service is new and for which neither the plan/issuer nor an independent database would have any information to use to calculate a QPA. These include: use of data from a subsequent year, use of independent databases, and use of a derivative of Medicare rates for new items and services.</span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Use of Data from a Subsequent Year.</b> If a plan or issuer gains sufficient data in subsequent years, it must use the data from the first year it has sufficient data to calculate the QPA. The rates must have been in place on Jan. 31 of the year immediately preceding the year in which the data will be used, and the rates must account for at least 25% of the total number of claims paid for that item or service for that year with respect to all plans of the sponsor (or administering entity). The departments note that the 25% rule is intended to prevent “selective contracting practices” by plans and issuers that might inappropriately depress the QPA.</span></span></span></li> </ul> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Use of Independent Databases. </b>In instances where a plan or issuer does not have sufficient information to calculate the QPA, they must use payment information from an independent database free of any conflicts of interest. The departments do not identify a single database; rather, they establish criteria to identify an eligible database. State all-payer claims databases are categorically eligible.</span></span></span></li> </ul> <p style="margin-left:48px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Other third party databases may be eligible if they meet a number of criteria. First, the databases must not be affiliated with or owned or controlled by any issuer or provider, or any member of the same controlled group as the plan/issuer or provider. The departments discuss several scenarios that would deem a plan ineligible based on affiliations and seek comment on whether they also should disqualify any databases owned by, controlled by, or affiliated with a plan sponsor or third party administrator. Second, the database must have sufficient information reflecting in-network amounts, but the rule but does not establish a threshold or definition for “sufficient.” Finally, the regulations require that the database have the ability to distinguish amounts paid to providers and facilities by commercial payers so as to not include rates from payers excluded from consideration (e.g. Medicare, Medicaid).</span></span></span></p> <p style="margin-left:48px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The regulations describe how plans and issuers must use this data to calculate the QPA, including prescribing the data that must be used, defining the appropriate year for the data, and how the data must be trended forward. Plans and issuers are required to use a consistent methodology when accessing information from databases for purposes of calculating the QPA. Finally, plans and issuers are responsible for the fees associated with accessing data from the database.</span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>New Items and Services. </b>The regulations establish an approach for calculating the QPA when neither the plan/issuer nor an independent database has sufficient data to calculate the QPA because the item or service is new or the associated code was “substantially revised.” In these instances and until sufficient data is available, plans and insurers must use a code for a related service and then adjust it based on the ratio between the Medicare rate for the new code and the Medicare rate for the related code. </span></span></span></li> </ul> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Requirements on Insurers to Share Information with Providers: </b>The law requires plans and issuers to share information with providers about the QPA and directed the departments to specify the information to be shared and when to share it. The regulations require plans and issuers to provide in writing, either on paper or electronically, to the provider: that the QPA is serving as the recognized amount for purposes of determining cost-sharing; the value of the QPA; a statement certifying that the QPA was calculated consistent with these regulations; and a statement that the provider may enter into a 30-day open negotiation period with the plan or issuer. Providers may request additional information from the plan or issuer, such as whether non-fee-for-service rates were included in the calculation, whether a related service code was used, and, if applicable, which database was used to calculate the QPA. If applicable and at the provider’s request, the plan or issuer must provide a statement that the contracted rates include risk-sharing, bonus, penalty, or other incentive-based or retrospective payments or payment adjustments.</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> January 1, 2022</span></span></span></p> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></p> <ul> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> <ul style="list-style-type:circle"> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 103. Determination of out-of-network rates to be paid by health plans; Independent dispute resolution process.</span></span></span></li> </ul> </li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: </b>See the following sections of the Code of Federal Regulations, as discussed in the <a href="https://www.govinfo.gov/content/pkg/FR-2021-07-13/pdf/2021-14379.pdf" style="color:#0563c1; text-decoration:underline">Interim Final Rule: Requirements Related to Surprise Billing; Part I </a></span></span></span> <ul style="list-style-type:circle"> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>ERISA: </b>29 CFR Part 2590<b> </b></span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Individual and Fully Insured Markets: </b>45 CFR 149.140</span></span></span></li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Federal Employee Health Benefit Plans:</b> 5 CFR 890.114</span></span></span></li> </ul> </li> <li style="margin-left:8px"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance: </b>N/A</span></span></span></li> </ul> <p>&nbsp;</p> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions </b></span></span></span></p> <ol> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Is the QPA what I should expect in reimbursement from the plan?</b> The law and regulations did not establish the QPA for purposes of provider reimbursement. However, there is nothing prohibiting a plan from remitting the value of the QPA to the provider as the initial payment amount if the plan believe that constitutes an appropriate amount in reimbursement for the given provider/service. However, providers are not obligated to accept the initial payment as payment in full and may negotiate with the plan to obtain fair compensation. Should negotiation fail, the provider may submit the claim for adjudication through the IDR process. </span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>When will the insurer share the QPA with providers?</b> The insurer must send the QPA information, along with an initial payment (or note of denial), within 30 days of receiving a clean claim.</span></span></span></li> <li><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What happens if the insurer never sends the QPA to the provider?</b> The insurer would be in violation of the law and regulations. Providers would have the option to alert regulators for potential oversight and enforcement actions. </span></span></span></li> </ol> <p>&nbsp;</p> <p>&nbsp;</p> <ul> </ul> </div> </li> <!-- item04 --> <li class="a-items"><input id="z4" name="ac" type="checkbox" /> <label for="z4"> Notice and Consent Process</label> <div class="a-content"> <p><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Under development</b></span></span></span></p> <ul> </ul> </div> <b> </b></li> <!-- item05 --> <li class="a-items"><b><input id="z5" name="ac" type="checkbox" /> <label for="z5"> Continuity of Care</label> </b> <div class="a-content"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What It Is: </b>This section of the law provides for continuity of services for enrollees of health plans when there is a change in the plans’ provider network. These protections extend to individuals defined as a “continuing care patient” and include patients who are undergoing a course of treatment for a serious or complex condition, undergoing institutional or inpatient care, scheduled to undergo non-elective surgery including post-operative care, pregnant and undergoing treatment, or terminally ill and receiving services. Plans are required to ensure continuing care patients receive timely notification of changes in the network status of providers and facilities. Such patients will have up to 90 days of continued coverage at in-network cost sharing to allow for a transition of care to an in-network provider.</span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> January 1, 2022</span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></b></p> <ul> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 113. Ensuring continuity of care.</span></span></span></b></li> </ul> <b> </b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: </b>N/A</span></span></span></b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance:</b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><a href="https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FAQs%20About%20ACA%20%26%20CAA%20Implementation%20Part%2049_MM%20508_08-20-21.pdf" style="color:#0563c1; text-decoration:underline">FAQs</a><span class="MsoHyperlink" style="color:#0563c1"><span style="text-decoration:underline"> regarding timing for additional guidance on continuity of care provision</span></span></span></span></span></b></li> </ul> <b> </b></li> </ul> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions</b></span></span></span></b></p> <ol> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Will these provisions go into effect on January 1, 2022? </b>Yes. According to the Departments FAQs, these provisions will go into effect on January 1, 2022. However, the Departments will be unable to provide additional guidance to providers and plans by that time. Pending further guidance, the Departments ask providers and plans to use their best judgement in implementing these provisions.</span></span></span></b></li> </ol> <ol start="2"> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>A specialist in our health system saw a patient once but did not begin a course of treatment. Does this patient qualify as a “continuing care patient?”</b> Absent additional federal guidance, we encourage providers to use their best judgement in determining which patients qualify as continuing care patients. We understand, for example, that many plan/provider contracts include provisions regarding continuity of care. We believe such provisions are a reasonable starting point to help determine who may qualify as a “continuing care patient” under these provisions.</span></span></span></b></li> </ol> <ol start="3"> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>My organization is treating a continuing care patient. However, the insurer now refuses to respond to any communications, such as prior authorizations. What do we do?</b> Absent additional federal guidance, we encourage providers to report such instances through the single complaint process that is being established for purposes of reporting violations of the No Surprises Act. We will provide more information on this process as it becomes available.</span></span></span></b></li> </ol> <p><b>&nbsp;</b></p> <ul> </ul> </div> <b> </b></li> <!-- item06 --> <li class="a-items"><b><input id="z6" name="ac" type="checkbox" /> <label for="z6"> Provider Directories</label> </b> <div class="a-content"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What It Is: </b>Beginning for health plan years on or after Jan. 1, 2022, plans will be required to establish a verification process to ensure accurate provider directories, a response protocol for individuals inquiring about the network status of a provider, and a publicly accessible provider database. These provider directory requirements do not pre-empt existing state law, and patients that relied on inaccurate provider directory information would only be subject to the in-network cost sharing amounts. The law requires that health plans verify and update provider directory information no less than every 90 days (or within two days of receiving notice of a change), as well as establish a procedure for removal of providers who are no longer in network. Plans are required to respond to individuals inquiring about the network status of a provider or facility within one business day of the inquiry and must retain records of the inquiry for two years. Plans must have a web-based provider directory that includes the provider and facility contact information, specialty information, direct or indirect contractual relationship with the plan, and digital contact information. Health plans also will be required to make information available on their websites and through other plan communications regarding balance-billing protections. Such information also must include the appropriate federal and state contact information for consumers to report any violations. Plans also are required, where state law applies, to provide information regarding allowable charges by non-contracting providers or facilities and any consumer cost-sharing obligations. </span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> January 1, 2022</span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></b></p> <ul> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 116. Protecting patients and improving the accuracy of provider directory information.</span></span></span></b></li> </ul> <b> </b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: </b>N/A</span></span></span></b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance:</b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><a href="https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FAQs%20About%20ACA%20%26%20CAA%20Implementation%20Part%2049_MM%20508_08-20-21.pdf" style="color:#0563c1; text-decoration:underline">FAQs</a><span class="MsoHyperlink" style="color:#0563c1"><span style="text-decoration:underline"> regarding timing for additional guidance on provider directory provision</span></span></span></span></span></b></li> </ul> <b> </b></li> </ul> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions</b></span></span></span></b></p> <ol> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Will these provisions go into effect on January 1, 2022? </b>Yes. According to the Departments’ FAQs, these provisions will go into effect on January 1, 2022. However, the Departments will be unable to provide additional guidance to providers and plans by that time and therefore anticipate exercising enforcement discretion. The Departments indicate that plans will not be deemed out of compliance so long as they impose a cost-sharing amount that is not greater than the cost-sharing amount that would be imposed for items and services furnished by a participating provider. Pending further guidance, the Departments ask providers and plans to use their best judgement in implementing these provisions.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>The health plan terminated our contract. Do we have any responsibilities with respect to updating the provider directory?</b> At this point, we do not believe providers have any additional responsibilities as a result of the No Surprises Act. However, we encourage providers to raise with the plan the issue of updating the provider directory as part of the termination process for the contract.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>We assessed the cost-sharing consistence with the remittance from the plan. Do we still owe a rebate to the consumer, including with interest?</b> Pending further guidance, we do believe that providers are responsible for returning any excess cost-sharing collected to the consumer with interest. </span></span></span></b></li> </ol> <p><b>&nbsp;</b></p> <ul> </ul> </div> <b> </b></li> <!-- item07 --> <li class="a-items"><b><input id="z7" name="ac" type="checkbox" /> <label for="z7"> Good Faith Estimates/Advanced Explanation of Benefits</label> </b> <div class="a-content"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What It Is: </b>Providers will be required to provide <i>good faith estimates</i> of all expected charges for scheduled services prior to care. For insured patients, the providers will transmit the good faith estimates to the patient’s health plan; the health plan will use that information to create an advanced explanation of benefits (AEOB) for the patient. For uninsured patients, the provider will send the estimates directly to the patient.&nbsp;</span></span></span></b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">While the AHA continues to press the Departments to only require these good faith estimates for scheduled services <u>upon request</u>, we believe they are currently interpreting the statute as requiring these for every scheduled service, regardless of whether the patient has asked for such an estimate. We will continue to press for clarification on this point, as well as note the tremendous undertaking it would be for providers to develop and transmit these estimates for every scheduled service. </span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Timeline:</b> </span></span></span></b></p> <table class="MsoTableGrid" style="border-collapse:collapse; border:none"> <tbody> <tr> <td style="border-bottom:1px solid black; width:216px; padding:0in 7px 0in 7px; border-top:1px solid black; border-right:1px solid black; border-left:1px solid black" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Scheduled services &lt;3 days out</span></span></span></b></p> </td> <td style="border-bottom:1px solid black; width:354px; padding:0in 7px 0in 7px; border-top:1px solid black; border-right:1px solid black; border-left:none" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Not required</span></span></span></b></p> </td> </tr> <tr> <td style="border-bottom:1px solid black; width:216px; padding:0in 7px 0in 7px; border-top:none; border-right:1px solid black; border-left:1px solid black" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Scheduled services 3-9 days out</span></span></span></b></p> </td> <td style="border-bottom:1px solid black; width:354px; padding:0in 7px 0in 7px; border-top:none; border-right:1px solid black; border-left:none" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">provider must provide the good faith estimate no later than <b><u>1 business day</u></b> after the date of scheduling</span></span></span></b></p> </td> </tr> <tr> <td style="border-bottom:1px solid black; width:216px; padding:0in 7px 0in 7px; border-top:none; border-right:1px solid black; border-left:1px solid black" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Scheduled services 10+ days out</span></span></span></b></p> </td> <td style="border-bottom:1px solid black; width:354px; padding:0in 7px 0in 7px; border-top:none; border-right:1px solid black; border-left:none" valign="top"> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">provider must provide the good faith estimate no later than <b><u>3 business day</u></b> after the date of scheduling</span></span></span></b></p> </td> </tr> </tbody> </table> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><i><span style="font-size:10.0pt"><span style="line-height:107%">Note: Good faith estimates are also required as part of the notice and consent process related to balance billing out-of-network patients. In the case of the notice and consent process, good faith estimates may be required for same-day services. </span></span></i></span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Patient-Provider Dispute Resolution Process: </b>The statute lays out a dispute resolution process for uninsured patients who are billed an amount that is “substantially in excess” of their good faith estimate of expected charges. Upcoming regulations are expected to provide more detail on this process, including a process for certifying and selecting dispute resolution entities and a participation fee for dispute resolution process. </span></span></span></b></p> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Effective Date:</b> </span></span></span></b></p> <ul> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Good faith estimates for <b><u>uninsured</u></b> patients <span style="font-family:Wingdings">à</span> January 1, 2022</span></span></span></b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Good faith estimates for <b><u>insured</u></b> patients, advanced EOBs <span style="font-family:Wingdings">à</span> TBD</span></span></span></b></li> </ul> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Helpful Links:</b></span></span></span></b></p> <ul> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Statute: </b>See the following sections of the “No Surprises Act” as part of the <a href="https://www.congress.gov/bill/116th-congress/house-bill/133/text" style="color:#0563c1; text-decoration:underline">Consolidated Appropriations Act, 2021</a><b> </b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 111. Consumer protections through health plan requirement for fair and honest advance cost estimate.</span></span></span></b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Sec. 112. Patient protections through transparency and patient-provider dispute resolution </span></span></span></b></li> </ul> <b> </b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Regulations: N/A</b></span></span></span></b></li> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Other Federal Guidance:</b></span></span></span> </b> <ul style="list-style-type:circle"> <li style="margin-left:8px"><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><a href="https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FAQs%20About%20ACA%20%26%20CAA%20Implementation%20Part%2049_MM%20508_08-20-21.pdf" style="color:#0563c1; text-decoration:underline">FAQs delaying enforcement for insured estimates, advanced EOBs</a></span></span></span></b></li> </ul> <b> </b></li> </ul> <p><b>&nbsp;</b></p> <p><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Frequently Asked Questions</b></span></span></span></b></p> <ol> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Is the government delaying enforcement of these requirements? </b>The government is delaying enforcement of the good faith estimates for <b><u>insured</u></b> patients and the advanced EOBs. Providers will still be required to provide <b><u>uninsured</u></b> patients with good faith estimates for scheduled services beginning January 1, 2022.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Do these policies apply to all scheduled services? </b>We believe the answer to be yes based on language included the Departments’ FAQs; however, we continue to press for clarification.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>In instances when there are multiple providers (e.g., a surgeon, anesthesiologist, and facility), is the facility responsible for compiling estimates from all providers (even the ones that they do not typically handle billing for)? </b>&nbsp;Further guidance is required from the Departments. However, for purposes of the notice and consent provisions related to balance billing out-of-network patients, we note that facilities <u>are</u> responsible for compiling estimates from different providers when the providers seek to balance bill for post-stabilization services only. In all other instances, i.e., scheduled care, the facility <u>is not</u> required to compile these estimates on behalf of other providers. However, they may choose to do so.<b> </b></span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>What happens if a provider does not provide the good faith estimates? </b><span style="color:black">Any provider or facility found to be in violation of this requirement could be subject to penalties under state and federal law, including civil monetary penalties. <i>(Citation: Section 2799B-4)</i></span></span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How should providers send the good faith estimates to <u>uninsured</u> patients? </b>The good faith estimates for uninsured patients or patients not using their health insurance coverage for a particular item or service must be sent directly to the patient. We expect the Departments to provide additional guidance in forthcoming regulations.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How should providers send the good faith estimates for <u>insured</u> patients to the patient’s health plans? </b>According to the FAQs delaying this requirement, technical standards will be developed for the transmission of these estimates prior to implementation of this requirement.</span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>Do these policies apply to patients with non-compliant health insurance coverage (e.g., short-term limited duration plans, association health plans, reference-based pricing plans, and/or health sharing ministries)?</b> Yes, these policies apply to all patients, regardless of whether they are covered by insurance or their insurance type. <b>&nbsp;&nbsp;&nbsp;</b></span></span></span></b></li> <li><b><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif"><b>How do these requirements interact with the notice and consent requirements for balance billing? </b>In some limited instances, an out-of-network facility or provider may seek to obtain the patient’s consent to balance bill. In those cases, the facility or provider is required to follow the notice and consent process established by the Departments. The notice must include a good faith estimate of expected charges, and the facility/provider must calculate the estimate in the same way it would under this provision. Additional guidance on how to calculate the good faith estimates is anticipated in future guidance. </span></span></span> </b> <ul> </ul> <b> </b></li> </ol> </div> <b> </b></li> </ul> </div> <b><!-- <div class="tabcontent" id="Recertify"> <ul class="a-container"> <!== item01 == <li class="a-items"> <input id="b1" name="ad" type="checkbox" /> <label for="b1">item 1</label> <div class="a-content"> <p>====</p> </div> </li> </ul> <div> --><script> function openCity(evt, cityName) { var i, tabcontent, tablinks; tabcontent = document.getElementsByClassName("tabcontent"); for (i = 0; i < tabcontent.length; i++) { tabcontent[i].style.display = "none"; } tablinks = document.getElementsByClassName("tablinks"); for (i = 0; i < tablinks.length; i++) { tablinks[i].className = tablinks[i].className.replace(" active", ""); } document.getElementById(cityName).style.display = "block"; evt.currentTarget.className += " active"; } // Get the element with id="defaultOpen" and click on it document.getElementById("defaultOpen").click(); </script></b></div> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/surprise-medical-billing" class="topic" hreflang="en">Surprise Medical Billing</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_access_level"> <div>Access Level</div> <div><a href="/taxonomy/term/279" hreflang="en">Member</a></div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Tue, 14 Sep 2021 15:55:07 +0000 cdailey_drupal 679490 at https://www.aha.org Fact Sheet: COVID-19 Related Payer Mix Changes Threaten 340B Hospital Eligibility https://www.aha.org/fact-sheets/2021-09-08-fact-sheet-covid-19-related-payer-mix-changes-threaten-340b-hospital <span class="title">Fact Sheet: COVID-19 Related Payer Mix Changes Threaten 340B Hospital Eligibility</span> <span class="uid"><span>dsamuels_drupal</span></span> <span class="created">Sep 08, 2021 - 09:25 AM</span> <div class="body"><div class="container row"> <div class="row"> <div class="col-md-8"> <h2>Background on the Issue:</h2> <p>The COVID-19 pandemic has ravaged the United States, with approximately 40 million people infected and nearly 650,000 people dead through August 2021. On the front lines of this devastating virus are our nation’s hospitals and health systems, which have collectively cared for nearly 2 million COVID-19 patients since the pandemic began. Mandatory shutdowns of non-emergent procedures to make way for increased demand for COVID-19 care resulted in strained financial and operational resources for hospitals across the U.S. These actions, while necessary, created an unfortunate consequence – significantly reduced patient volumes that altered some hospitals’ payer mixes, especially with respect to the proportion of a hospital’s patients that were insured through Medicaid or Medicare supplemental security income (SSI). View the entire Fact Sheet below. </p> <h2>How Does this Impact 340B Eligibility?</h2> <p><img alt="Impact of COVID-19 on Hospitals’ DPP" data-entity-type="file" data-entity-uuid="866d17e2-6efc-47a5-a993-2ac041384967" height="274" hspace="10px" src="/sites/default/files/inline-images/image-impact-of-covide-fact-sheet-340b-related-payer-mix-changes-9-2021.png" vspace="10 px" width="355" class="align-right" />One of the primary eligibility criteria for hospitals in the 340B program is a measurement of the hospital’s volume of inpatient Medicaid and Medicare SSI patients, known as the “DSH Adjustment Percentage Threshold.”<sup>1</sup> Hospitals report their share of patients who are Medicaid and Medicare SSI called the “DPP” on their Medicare cost report, which they file annually with the Centers for Medicare &amp; Medicaid Services (CMS). A hospital’s Medicare DPP is then converted to a DSH adjustment percentage. The Health Resources and Services Administration (HRSA), which oversees the 340B program, uses the DSH adjustment percentage to determine 340B eligibility.</p> <p>As patients avoided inpatient care and non-emergent procedures due to the pandemic, some hospitals experienced precipitous drops in their number of Medicaid inpatients (numerator). At the same time, while Total Patient days (denonimator) also dropped due to the pandemic, they were partially offset by the number of COVID-19 inpatients, many of whom were Medicare patients. For some hospitals this drop in the Medicaid ratio was not offset by any increase in the Medicare SSI ratio because CMS has not updated these ratios since the pandemic.<sup>2</sup> As a result, for some hospitals the decrease in their Medicaid ratio has driven a decrease in their DPP and thereby has decreased their DSH adjustment percentage (see graphic).<sup>3</sup></p> <h2>Why is This Issue Important?</h2> <p><img alt="right callout" data-entity-type="file" data-entity-uuid="379af91d-a950-46f7-9fe6-b6ab1bd7697d" height="415" src="/sites/default/files/inline-images/image-left-callout-fact-sheet-340b-related-payer-mix-changes-9-2021.png" width="297" class="align-right" />The 340B program was designed to help hospitals stretch their scarce federal resources to provide more comprehensive services to the patients they serve. Savings generated from the program are often used by hospitals to support important patient programs, such as diabetes assistance programs, medication therapy management and mental health treatment. Some hospitals, especially those in rural areas, use their savings to keep the doors of their facility open and to maintain important treatment services like infusion centers for cancer patients so that these patients do not have to travel far distances to access their treatments. As hospitals are forced out of the 340B program due to COVID-19-related changes to their DSH adjustment percentage, many of these important programs and services that depend on savings from the 340B program are at risk. The downstream effects of losing 340B eligibility will directly impact patients and their ability to access the care they need.</p> <h2>How do we Solve this Issue?</h2> <p>Congress or the Administration should act to ensure that 340B hospitals that were participating in the program at the start of the COVID-19 public health emergency and may have experienced changes to their DSH adjustment percentage in FY 2020 or FY 2021 due to the COVID-19 pandemic retain their 340B eligibility. Hospitals should not be penalized by losing their 340B eligibility due to temporary payer mix changes that were a direct result of the COVID-19 pandemic. Instead, programs like 340B that provide critical resources to hospitals should be safeguarded while hospitals continue to be on the front lines of the pandemic.</p> <p>Legislation has been introduced in the Senate, S. 773, and the House, H.R. 3203, to provide 340B hospitals with certainty by allowing these hospitals to continue to access the 340B program during the public health emergency. In addition, the AHA continues to call on the Biden Administration to provide this same flexibility through the 1135 waiver process. If swift action is not taken to address this issue, it is very likely that some 340B hospitals may lose access to the program, thereby jeopardizing care for the patients and communities they serve</p> <p> </p> <p>________________________</p> <p><small><sup>1.</sup> For hospitals that wish to participate in the 340B program as disproportionate share hospitals (DSH), free-standing children’s hospitals (PED), or free-standing cancer hospitals (CAN), they must have a DSH adjustment percentage of at least 11.75%. For hospitals that wish to participate in the program as either a Rural Referral Center (RRC) or a Sole Community Hospital (SCH), that threshold is 8%.<br /><sup>2.</sup> CMS publishes Medicare SSI ratios that hospitals use as part of calculating their DPP and report these numbers on their annually filed cost report. However, to our knowledge these data are lagged and CMS has not updated the Medicare SSI ratio such that it would account for any changes to the ratio due to the COVID-19 pandemic.<br /><sup>3.</sup> Hospitals are required to notify HRSA, the agency that oversees the 340B program, if their DSH adjustment percentage falls below the required threshold percentage. When this occur, the hospital must terminate from the 340B program.</small></p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-body"> <h5 class="text-align-center"><a href="https://www.aha.org/system/files/media/file/2021/09/fact-sheet-340b-related-payer-mix-changes-9-2021.pdf" target="_blank"><strong>Download<br /> Fact Sheet: COVID-19 Related Payer Mix ChangesThreaten 340B Hospital Eligibility</strong></a></h5> <p class="text-align-center"><a href="https://www.aha.org/system/files/media/file/2021/09/fact-sheet-340b-related-payer-mix-changes-9-2021.pdf" target="_blank"><img src="/sites/default/files/2021-09/cover-fact-sheet-340b-related-payer-mix-changes-9-2021-342.png" /></a></p> </div> </div> </div> </div> </div></div> <div class="field_topics"> <div><a href="/topics/340b" class="topic" hreflang="en">340B</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_access_level"> <div>Access Level</div> <div><a href="/taxonomy/term/278" hreflang="en">Public</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_lead"><p>September 2021</p> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/09/fact-sheet-340b-related-payer-mix-changes-9-2021.pdf" type="application/pdf; length=69602" title="Fact Sheet: COVID-19 Related Payer Mix Changes Threaten 340B Hospital Eligibility">Fact Sheet: COVID-19 Related Payer Mix Changes Threaten 340B Hospital Eligibility</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Wed, 08 Sep 2021 14:25:07 +0000 dsamuels_drupal 679353 at https://www.aha.org Fact Sheet: AHA Priorities for Budget Reconciliation Package to Support America’s Hospitals and Health Systems https://www.aha.org/fact-sheets/2021-09-02-fact-sheet-aha-priorities-budget-reconciliation-package-support-americas <span class="title">Fact Sheet: AHA Priorities for Budget Reconciliation Package to Support America’s Hospitals and Health Systems</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">Sep 02, 2021 - 09:30 AM</span> <div class="body"><div class="container" style="margin-left: -15px;"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>Americans rely on hospitals and health systems to care for them when they are sick or injured and to help them improve and maintain their health. As such, it is critical that hospitals and health systems are there for their communities 24/7. The COVID-19 pandemic has demonstrated how essential hospitals and health systems are to their patients and to the public health of our country. It also has made clear the types of investments our health care system needs. These include investments in workforce and behavioral health; the accessibility and affordability of health care coverage; emergency preparedness; telehealth; and cybersecurity, among other areas. Federal investments in hospitals and health systems will lead to improved health and health care, as well as growth of American jobs and businesses and a sense of security and stability for our families and communities.</p> <h2>AHA Take</h2> <p><strong>It is imperative that Congress invest in America’s hospitals and health systems to ensure that the nation’s health care needs can be met today and into the future. The AHA supports investments in infrastructure, such as the health care workforce, behavioral health, the accessibility and affordability of health care coverage, emergency preparedness and the health care supply chain, telehealth and cybersecurity, among other areas.</strong></p> <h2>Recommended Actions:</h2> <h3>Strengthening the Health Care Workforce</h3> <p>The AHA urges Congress to prioritize funding for the infrastructure that supports the health care workforce needs of the country that were present before the pandemic and have been magnified in the wake of COVID-19. <strong>We need to support strengthening and diversifying the health care workforce by expanding nursing schools and training programs, as well as addressing the growing shortage of doctors by expanding medical schools and lifting the cap on Medicare-funded residency positions. In addition to expanding nursing and training programs, we urge the following legislation be included in reconciliation legislation:</strong></p> <ul><li><strong>Resident Physician Shortage Reduction Act of 2021 (S.834/H.R. 2256):</strong> This bill would help address physician shortages by adding 14,000 Medicare-funded residency slots.</li> <li><strong>Dr. Lorna Breen Health Care Provider Protection Act (S.610/H.R. 1667):</strong> This bill aims to prevent suicide, burnout and behavioral health disorders among health care professionals.</li> <li><strong>Healthcare Workforce Resilience Act (S.1024/H.R. 2255):</strong> This bill would expedite the visa authorization process for qualified international nurses to support hospitals facing staffing shortages.</li> <li><strong>Future Advancement of Academic Nursing (FAAN) Act (S.246/H.R 851):</strong> This bill would support nursing education and provide resources to boost student and faculty populations, as well as support educational programming as well as partnerships and research at schools of nursing.</li> </ul><h3>Increasing Access to Behavioral Health</h3> <p>The AHA urges Congress to prioritize funding for the behavioral health needs of the country. These investments will not only help to stymie the wave of unmet demand for behavioral health services that has been exacerbated by the COVID-19 pandemic, but also improve America’s overall health. In addition to prioritizing funding for behavioral health needs, the AHA supports the following legislation being included in reconciliation:</p> <ul><li><strong>Opioid Workforce Act of 2021 (S.1438)/Substance Use Disorder Workforce Act of 2021 (H.R. 3441):</strong> These bills would help address shortages of substance use disorder treatment providers by adding 1,000 Medicare-funded training positions in approved residency programs in addiction medicine, addiction psychiatry or pain medicine.</li> <li><strong>Fund Opportunities for Behavioral Health Providers to Acquire Interoperable Electronic Health Records:</strong> To date, behavioral health providers have not been included in federal health information technology (HIT) initiatives. Federal funding for HIT for behavioral health could enhance the integration of physical and behavioral health by facilitating better communication across the care continuum and with public health agencies.</li> <li><strong>Repeal the Institutions for Mental Disease (IMD) Exclusion:</strong> Current law prohibits Medicaid from paying the federal match for mental health treatment rendered to patients age 21-64 in IMDs. Current law allows a state option for payment for Medicaid beneficiaries age 21-64 with at least one substance use disorder; however, this provision expires on Sept. 30, 2023. To alleviate the dire shortage of inpatient psychiatric beds, Congress should repeal the IMD exclusion.</li> </ul></div> <div class="col-md-4"> <a href="/system/files/media/file/2021/09/fact-sheet-reconciliation-policies-to-include-0921-II.pdf" target="_blank" title="Click here to download the Fact Sheet PDF."><img alt="Fact Sheet: AHA Priorities for Budget Reconciliation Package to Support America’s Hospitals and Health Systems page 1." data-entity-type="file" data-entity-uuid="ce0a71c6-28e1-410b-b8bf-53bdbc8ef9bd" src="/sites/default/files/inline-images/Page-1-fact-sheet-reconciliation-policies-to-include-0921-II.jpg" style="border: solid #307fe2 1px;" class="align-center" /></a> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2021/09/fact-sheet-reconciliation-policies-to-include-0921-II.pdf" target="_blank" title="Click here to download the Fact Sheet PDF.">Download the Fact Sheet PDF</a></div> </center> </div> </div> </div> <h3>Improving Accessibility and Affordability of Health Care Coverage</h3> <p>The AHA urges Congress to prioritize funding to expand access to affordable health care coverage. Every day, the caregivers in America’s hospitals and health systems see how a lack of coverage stops patients from getting the right care, at the right time, in the right place. The AHA supports the following priorities to expand access to affordability and coverage be included in reconciliation:</p> <ul><li><strong>Extension of Health Insurance Marketplace Subsidies:</strong> The AHA supports further extension of provisions to reduce the cost of Marketplace coverage for all subsidy-eligible individuals and families and to expand eligibility for tax credit subsidies to more individuals.</li> <li><strong>Medicaid:</strong> The AHA supports providing health care coverage to individuals in states that did not expand Medicaid after the expansion of the Affordable Care Act.</li> </ul><h3>Resetting the IMPACT Act</h3> <p>The AHA supports the Resetting the Impact Act (TRIA) of 2021 (H.R. 2455) to take into account unforeseen changes since the passage of the Improving Medicare Post-Acute Care Transformation Act in 2014, by allowing policymakers to first complete the in-process collection of patient assessment data required to develop a unified payment model for post-acute care (PAC), as well as focus this effort on data that reflect current standard operations of the PAC field.</p> <h3>Prescription Drug Pricing</h3> <p>The cost of and access to prescription drugs are major concerns for hospitals and health systems. Continued rising drug prices, as well as shortages for many critical medications, are disrupting patient care and straining hospitals’ budgets and operations. The AHA is committed to working for action on policies that foster transparency, competition and value while preserving innovation.</p> <ul><li><strong>340B Disproportionate Share Hospital (DSH) Fix:</strong> The AHA supports providing temporary relief for any hospitals participating in the 340B Drug Pricing Program that had to leave the program due to changes in their patient mix as a result of the COVID-19 pandemic.</li> </ul><h3>Investing in Hospitals for Building Capacity for Emergency Preparedness and Response and Securing the Health Care Supply Chain</h3> <p>The AHA urges Congress to prioritize investments that are critical to ensuring the long-term sustainability and viability of hospitals. We support increased investments to maintain consistent and continuous access to medical supplies for hospitals and the entire health care system. The AHA urges the following provisions be included in reconciliation:</p> <ul><li>Provide direct capital investment through grants to hospitals by updating the Hill-Burton Act.</li> <li>Restore advance refunding for tax-exempt bonds (H.R. 2288, H.R. 2634, S.479) and expand the use of bank-qualified debt (H.R. 2634).</li> <li>Provide hospital funding to implement structural improvements to support emergency preparedness and response activities.</li> </ul><h3>Investing in Telehealth and Cybersecurity for Health Care</h3> <p>The AHA urges Congress to prioritize investment in telehealth and cybersecurity to ensure all patients have secure, sustained, equitable access to care using digital and information technologies. Hospitals, health systems and government agencies also require modernized data systems to better identify and respond to issues that affect health equity, racial and ethnic disparities, the quality of health care delivery and public health responses. The AHA supports the following bills and priorities and urges their inclusion in reconciliation:</p> <ul><li>strong&gt;Provide support for the FCC’s Rural Health Care Program: Provide an increase of $2 billion for the Federal Communications Commission’s (FCC) Rural Health Care Program to support broadband access and other digital and data infrastructure improvements, with specific funding to increase the program subsidy and offset the high upfront costs of “last mile” broadband connections for rural hospitals.</li> <li><strong>Expand the FCC COVID-19 Telehealth Program funded in the Coronavirus Aid, Relief, and Economic Security (CARES) Act and Consolidated Appropriation Act:</strong> This program provides offsets for hospitals’ telehealth infrastructure costs, including those related to telecommunications services, information services and devices (all hospitals should be eligible, regardless of tax status).</li> <li><strong>CONNECT for Health Act (S.1512/H.R. 2903), the Telehealth Modernization Act (S.368/H.R. 1332), the Protecting Rural Telehealth Access Act (S. 1988) and the TREAT Act (S.168/H.R. 708):</strong> These bills would remove Medicare’s limitations on telehealth and appropriately reimburse hospitals/providers for providing telehealth services (eliminating originating and geographic site requirements; expanding the types of technology that can be used for furnishing telehealth services, including audio-only connections; allowing hospitals to bill for the virtual care they provide; and remove licensing barriers).</li> <li><strong>Advance cybersecurity efforts</strong> by developing coordinated national defense measures, expanding the cybersecurity workforce, disrupting bad actors that target U.S. critical infrastructure and using a “whole of government” approach to increasing consequences for those who commit attacks.</li> </ul></div> <div class="field_topics"> <div><a href="/topics/legislative" class="topic" hreflang="en">Legislative</a></div> <div><a href="/topics/infrastructure" hreflang="en">Infrastructure</a></div> <div><a href="/topics/workforce" hreflang="en">Workforce</a></div> <div><a href="/topics/access-behavioral-health" hreflang="en">Access to Behavioral Health</a></div> <div><a href="/topics/access-health-coverage" hreflang="en">Access &amp; Health Coverage</a></div> <div><a href="/topics/current-emerging-payment-models" hreflang="en">Current &amp; Emerging Payment Models</a></div> <div><a href="/topics/drug-prices" hreflang="en">Drug Prices</a></div> <div><a href="/topics/emergency-readiness" hreflang="en">Emergency Readiness</a></div> <div><a href="/topics/supply-chain-management" hreflang="en">Supply chain management</a></div> <div><a href="/topics/telehealth" hreflang="en">Telehealth</a></div> <div><a href="/topics/cybersecurity" hreflang="en">Cybersecurity</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/09/fact-sheet-reconciliation-policies-to-include-0921-II.pdf" type="application/pdf; length=86503" title="Fact Sheet: AHA Priorities for Budget Reconciliation Package to Support America’s Hospitals and Health Systems">Fact Sheet: AHA Priorities for Budget Reconciliation Package to Support America’s Hospitals and Health Systems PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 02 Sep 2021 14:30:37 +0000 Matthew Diener 679292 at https://www.aha.org Fact Sheet: Reference-based Pricing https://www.aha.org/fact-sheets/2021-06-08-fact-sheet-reference-based-pricing <span class="title">Fact Sheet: Reference-based Pricing</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">Jun 08, 2021 - 03:02 PM</span> <div class="body"><h2>Background: What is reference-based pricing?</h2> <ul> <li>Some employers are moving away from offering traditional coverage with a provider network and instead are using reference-based pricing for some or all of services they cover. Under reference-based pricing, the employer (supported by a third party administrator [TPA] or other vendor) pays a set a price for each health care service instead of negotiating prices with providers. When a provider bills for the service, the payer remits the set amount. If the provider is dissatisfied with the payment, they can bill the patient for the unpaid portion of the claim.</li> <li>Some payers use reference-based pricing software to determine the price they will pay for a health care service. Although reference-based pricing software programs vary, the methodology includes collecting data on prevailing costs for medical services from CMS’s HCRIS (Healthcare Provider Cost Reporting Information System), benchmarking it against relevant types of hospitals and settings, further calibrating by severity level, and applying a margin factor.</li> <li>Federal and state law permit most payers to use reference-based pricing for out-of-network claims. However, any plan subject to network adequacy rules may not use this as a comprehensive payment strategy (e.g., Medicaid managed care, Medicare Advantage, and fully-insured individual and group products). Only employer-based plans regulated under ERISA may use reference-based pricing as a comprehensive payment strategy.</li> </ul> <h2>Adoption of Reference-based Pricing</h2> <ul> <li>To date, most payers that have used reference-based pricing have limited it to out-of-network emergency and laboratory claims.</li> <li>Increasingly, some payers are looking to replace the traditional provider network model with referencebased pricing for some or all of their medical spending. <ul> <li>A 2016 survey on employer benefits found that only 5 percent of employers utilized reference-based pricing in 2016, however, 60 percent of those surveyed planned to use reference-based pricing in the next 3 to 5 years.<sup><a href="#fn1">1</a></sup></li> </ul> </li> <li>The number of employers offering self-insured plans is growing, which increases the number of individuals covered under plans that are able to implement reference-based pricing. <ul> <li>The percent of employers offering self-insured plans rose from 28.5 percent in 1996 to 40.7 percent in 2016, including 78.5 percent of large employers, 29.2 percent of midsized employers, and 17.4 percent of small employers.</li> <li>In 2016, 57.8 percent of employees were covered under self-insured plans.<sup><a href="#fn2">2</a></sup></li> </ul> </li> <li>Smaller employers have shown greater interest than larger employers in reference-based pricing. There is a growing industry of third-party administrators targeting small businesses for reference-based pricing solutions.</li> <li>Large employers that use benefits to compete for workforce talent have shown less interest in this payment model, as it creates pain-points for their employees (balance billing and subsequent adjudication). However, some larger employers are using reference-based pricing for discreet services, such as knee and hip replacements.</li> <li>Recent changes to federal rules that expand access to association health plans could increase the number of individuals enrolled in plans that use this reimbursement strategy.</li> </ul> <h2>AHA Position</h2> <p>Reference-based pricing is bad for patients and the hospitals and health systems that serve them because it:</p> <ul> <li>Is a <strong>cost-containment strategy</strong> that simply pushes more of the cost of care away from the payer and onto patients and providers.</li> <li>Often leaves patients <strong>unaware that they may be subject to additional costs</strong>, making them financially vulnerable.</li> <li>Does <strong>not consider quality in the equation</strong>, as the reference price does not help direct patients to higher-quality providers.</li> <li>Creates <strong>“pain points” for consumers</strong> by leaving them stuck with unexpected bills and greater costs.</li> <li><strong>Increases bad debt</strong> for providers, making it more difficult for hospitals to meet their mission of caring for communities.</li> <li>Undermines <strong>broader health care planning</strong>, as providers have less ability to predict their patient mix and volume and their health care needs.</li> <li>Increases consumer demand for price and quality transparency, and <strong>reliable tools are not yet widely available.</strong></li> <li><strong>Ignores one of the largest drivers of growth in health care spending:</strong> prescription drugs − by excluding them from reference-based pricing programs.</li> <li>Will favor lower-cost alternatives and further erode society’s <strong>ability to finance social good activities, such as:</strong> <ul> <li>training the future workforce;</li> <li>conducting research;</li> <li>caring for the uninsured and underinsured; and</li> <li>maintaining emergency stand-by capacity in every community.</li> </ul> </li> </ul> <hr /> <h3>Sources</h3> <ol> <li id="fn1"><a href="http://images.respond.aonhewitt.com/Web/AonHewitt/%7B4eef02b6-ab2a-4fb7-958f-bade4f99ee0d%7D_00353_Health_Survey_2016_Report_v6.pdf?utm_source=eloqua&amp;utm_medium=email_&amp;utm_campaign=&amp;utm_source=confirmation&amp;utm_campaign=2016-health-care-survey&amp;utm_medium=lp&amp;elqTrackId=70ea94373075434a96ff9fe4aaa3e703&amp;elqaid=5956&amp;elqat=2" target="_blank">http://images.respond.aonhewitt.com/Web/AonHewitt/%7B4eef02b6-ab2a-4fb7-958f-bade4f99ee0d%7D_00353_Health_Survey_2016_Report_v6.pdf?utm_source=eloqua&amp;utm_medium=email_&amp;utm_campaign=&amp;utm_source=confirmation&amp;utm_campaign=2016-health-care-survey&amp;utm_medium=lp&amp;elqTrackId=70ea94373075434a96ff9fe4aaa3e703&amp;elqaid=5956&amp;elqat=2</a></li> <li id="fn2"><a href="https://www.ebri.org/pdf/briefspdf/EBRI_IB_442.pdf" target="_blank">https://www.ebri.org/pdf/briefspdf/EBRI_IB_442.pdf</a></li> </ol> </div> <div class="field_topics"> <div><a href="/topics/access-health-coverage" class="topic" hreflang="en">Access &amp; Health Coverage</a></div> <div><a href="/topics/health-insurance" hreflang="en">Health Insurance</a></div> <div><a href="/topics/current-emerging-payment-models" hreflang="en">Current &amp; Emerging Payment Models</a></div> <div><a href="/topics/payer-relations" hreflang="en">Payer Relations</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/06/fact-sheet-reference-based-pricing-1118.pdf" type="application/pdf; length=503347" title="Fact Sheet: Reference-based Pricing">Fact Sheet: Reference-based Pricing PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Tue, 08 Jun 2021 20:02:56 +0000 Matthew Diener 677869 at https://www.aha.org Fact Sheet: Infrastructure Investments Needed to Support Access to Care in Rural America https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-infrastructure-investments-needed-support-access-care-rural <span class="title">Fact Sheet: Infrastructure Investments Needed to Support Access to Care in Rural America</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:58 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>Every day, roughly 57 million rural Americans depend on their hospital as an important source of care as well as a critical component of their area’s economic and social fabric. Rural hospitals and health systems have been on the front lines of the COVID-19 pandemic, and have remained committed to ensuring local access to high-quality, affordable health care, including assisting with testing, contact tracing and vaccine deployment. Yet, rural hospitals face unprecedented financial and health care challenges. This includes severely deteriorated hospital finances, aging physical plants, and lack of broadband and high-speed internet; an aging and burnt-out workforce; and a patient population that is increasingly older, poorer and sicker than other parts of the country. We cannot leave our rural communities behind. Federal investment is necessary to ensure that rural communities are able to preserve access to essential health care services. New infrastructure investments must be made to ensure rural communities can thrive in the health care system of the 21st century.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to prioritize funding for the infrastructure that supports rural hospitals and the communities they serve. Key areas of investment include physical infrastructure and “right-sizing,” capacity to enable digital health, workforce support and access to behavioral health services.</strong></p> <h2>Why?</h2> <ul> <li><strong>Rural Hospitals Need Support for Physical Infrastructure Upgrades and “Right-Sizing.”</strong> Many rural hospitals need funding support so they can maintain, update and transform their physical plant to serve the current and future needs of their communities. For example, if a rural hospital chooses to convert to the newly created Rural Emergency Hospital provider type or strategically shift their focus to outpatient services, facility renovations or improvements would be necessary to restructure how and where the hospital offers its services. Additionally, rural hospitals need funding to “rightsize” or reconfigure their services beyond their “four walls” to better help parts of their community with limited access to health care, such as mobile screening clinics and temporary care sites, among others. Moreover, many rural hospitals are shut out of traditional capital markets and often operate in the red – meaning they have little to no margins to finance large infrastructure improvement projects.</li> <li><strong>Expanded Broadband Access will Improve the Health of Rural Americans.</strong> According to the Federal Communications Commission’s (FCC) 2019 Broadband Deployment Report, 26.4% of rural residents did not have access to minimum broadband speeds, compared to 1.7% in urban areas. Lack of affordable, high-capacity broadband impedes routine health care operations for rural hospitals (such as widespread use of electronic health records and imaging tools) and severely limits their availability to provide telehealth services. Access to broadband also is essential to reducing health disparities by connecting patients in rural and underserved areas with the full spectrum of caregivers, including behavioral health providers. While the FCC Rural Health Care Program has been an important funding stream to help rural providers obtain telecommunications and broadband services, significant additional investment is required to increase the level of subsidies and make other program changes to meet increased demand. Rural hospitals also need support to offset the high upfront costs related to construction for “last mile” broadband connectivity, which affects their ability to provide care using digital health technologies.</li> <li><strong>Rural Hospitals Need Support to Build Telehealth Capacity.</strong> The COVID-19 public health emergency has illustrated how effective and critical telehealth services are to ensuring access to care in rural communities. However, rural hospitals continue to face challenges that can impede their efforts in providing access to care. <ul> <li>The substantial upfront and ongoing costs of establishing and maintaining telehealth infrastructure can be a significant barrier for rural hospitals. Continued funding is needed for programs to offset infrastructure costs related to telecommunications services, information services, and devices necessary to provide telehealth to patients at their homes or mobile locations, especially those patients who are unable to secure other points of access to the health care system. It is crucial that all rural hospitals, regardless of ownership status, be eligible for funding to support telehealth in their communities.</li> <li>Removing certain policy barriers is critical to enabling telehealth in rural communities as well as expanding access to health care services that may not otherwise be sustained locally. This includes eliminating geographic and setting requirements, ensuring adequate reimbursement for originating sites, and allowing Medicare coverage and payment for audio-only communication, as clinically appropriate. Rural health clinics and federally qualified health centers also should be allowed to serve as distant sites for the provision of telehealth services, and licensure requirements should be coordinated across state lines.</li> </ul> </li> <li><strong>Federal Investment Is Needed to Bolster the Rural Health Care Workforce.</strong> Recruitment and retention of health care professionals is an ongoing challenge and expense for rural hospitals. According to the Health Resources and Services Administration, more than 60% of the health professional shortage areas (HPSAs) are located in rural areas. Targeted programs that can help address workforce shortages in rural communities should be supported and expanded, including: <ul> <li>Increasing the number of residency slots eligible for Medicare funding;</li> <li>Funding educational loan pay-downs and vouchers for clinicians and other front-line workers;</li> <li>Providing grants to expand, modernize and support schools of medicine and schools of nursing in rural, underserved areas or minority-serving organizations; and</li> <li>Bolstering the capacity of schools of nursing and allied health professionals, and increasing the number of faculty.</li> </ul> </li> <li><strong>Rural Communities Need More Access Points for Behavioral Health Care.</strong> Rural communities face significant barriers to accessing behavioral health services. According to Centers for Medicare &amp; Medicaid Services’ data, of the 595 psychiatric hospitals operating in the U.S., only 73 (12%) are located in rural areas. Some of the most difficult-to-access services are among the most needed in rural areas, including mental health and substance use disorder services to address high rates of suicide and opioid overdose. To address these shortages, it is essential that hospitals are able to serve patients experiencing mental illness and/or substance use disorders both in-person and remotely. To enable this, funding should be provided for end-user devices to upgrade audio-video technology to support telehealth in the location where patients are receiving behavioral health care, which may include the patient’s home for certain psychotherapy and addiction recovery services. It also is critical that funding be provided for the construction of new sites of care to improve access to behavioral health services.</li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> <div><a href="/topics/rural-issues" hreflang="en">Rural issues</a></div> <div><a href="/topics/advocacy-public-policy" hreflang="en">Advocacy &amp; Public Policy</a></div> <div><a href="/topics/legislative" hreflang="en">Legislative</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-rural-infrastructure-0521.pdf" type="application/pdf; length=55061" title="Fact Sheet: Infrastructure Investments Needed to Support Access to Care in Rural America">Fact Sheet: Infrastructure Investments Needed to Support Access to Care in Rural America PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:58:23 +0000 Matthew Diener 677547 at https://www.aha.org Fact Sheet: Federal Investment in Behavioral Health Infrastructure Needed to Address Mounting Crisis https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-federal-investment-behavioral-health-infrastructure-needed <span class="title">Fact Sheet: Federal Investment in Behavioral Health Infrastructure Needed to Address Mounting Crisis</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:53 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>Behavioral health needs have long gone under-addressed in the U.S., and the COVID-19 pandemic has and will continue to exacerbate this issue. While some have been able to access care via telehealth during the pandemic, hospitals will struggle to sustain and expand offerings that meet the large scale and severity of America’s behavioral health care needs. Children and adolescents in particular face critical care shortages, especially because of the specialized nature of their treatment.</p> <p>To address behavioral health issues, hospitals need support to provide safe facilities with appropriate equipment and tailored services — which are widely under-reimbursed, and thus challenging to maintain. This will include procuring adequate end-user audio-video equipment, building remote clinics, and installing interoperable electronic health records (EHRs) to improve information sharing.</p> <p>It is essential that hospitals and health systems are able to serve patients experiencing mental illness and/or substance use disorders both in-person and remotely and that capacity to respond to the unique behavioral health needs of children and adolescents is expanded. Inpatient psychiatric facilities, as well as general acute care hospitals that offer inpatient and outpatient behavioral health programs like partial hospitalization and opioid treatment programs, face unique infrastructure challenges that are critical to address now before the surge of behavioral health needs stemming from the pandemic becomes insurmountable.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to prioritize funding for the infrastructure that supports the behavioral health needs of the country. These investments will not only help to stymie the wave of unmet demand for behavioral health services that has been growing for decades, but also provide the basis for better overall physical health for Americans.</strong></p> <h2>Why?</h2> <ul> <li><strong>Behavioral health conditions — including mental illness and substance use disorders — are highly prevalent, but more often than not go untreated; the COVID-19 pandemic has contributed to increases in acute behavioral health episodes.</strong> One in five American adults has a behavioral health condition; before the pandemic, nearly 60% of adults with behavioral health disorders reported not receiving services for their conditions. The stresses of the COVID-19 pandemic have compounded these concerns: One in three adults reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019. The Centers for Disease Control and Prevention (CDC) reported that overdose deaths spiked after the start of the pandemic, driven by synthetic opioids like fentanyl. Clearly, the demand for behavioral health services is high.</li> <li><strong>The nation is in dire need of more access points for care, especially clinicians and inpatient psychiatric beds.</strong> The availability of inpatient psychiatric and 24-hour residential treatment beds has declined significantly over the past five decades; while some facilities and units have closed in an attempt to shift care to community-based and outpatient programs, most have ceased operations due to flagging financials. As a result, over 100 million Americans live in areas that have a <a href="https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" target="_blank">shortage</a> of mental health professionals. Surging COVID-19 cases have exacerbated these shortages, as thousands of psychiatric, detox and drug-rehabilitation beds were converted to serve patients with the virus.</li> <li><strong>Children and adolescents face a uniquely dire shortage of care.</strong> Only about 20% of children with mental, emotional, or behavioral disorders <a href="https://www.aacap.org/AACAP/Press/Press_Releases/2018/Severe_Shortage_of_Child_and_Adolescent_Psychiatrists_Illustrated_in_AAACP_Workforce_maps.aspx" target="_blank">receive care</a> from a specialized mental health care provider. The pandemic has taken a serious toll on pediatric mental health: during the summer of 2020, hospitals saw a 20% increase in suicide attempts and more than a 40% increase in disruptive behavior disorders among children and youths. These vulnerable patients have unique behavioral health needs that require specialized facilities with appropriate equipment (e.g., child-size furniture) and space for safely addressing psychological, developmental, educational and neuropsychological concerns.</li> <li><strong>Telehealth can improve access to care, but capacity is limited by upfront costs and lack of broadband infrastructure.</strong> According to the Federal Communications Commission, more than 20 million Americans still lack access to high-speed broadband. Further, many remote clinics — and patients’ own homes — lack adequate equipment to meet the needs of underserved patients; this includes sufficient two-way audio-video communication equipment and private and soundproof examination rooms. Telehealth has long been considered a clinically appropriate strategy to expand access to behavioral health services, but hospitals and health systems need support to scale up their telehealth services to meet heightened long-term demand.</li> <li><strong>Compliance costs approach $2 billion annually.</strong> Mental illnesses carry an increased risk of self-harm, so psychiatric facilities are constantly working to keep patients safe; however, psychiatric facilities must juggle outdated regulations and inconsistent accreditation surveys in order to remain in compliance with federal mandates. Changing interpretations of regulations have forced psychiatric providers to retrofit their facilities in order to reduce unclearly defined safety hazards or face termination of their Medicare contracts. Facilities across the country have invested in new, specially designed and extremely expensive doors, bathroom fixtures, windows, ceiling tiles, beds and sensors in an attempt to avoid citations. In some instances, psychiatric units have closed permanently after determining they are financially unable to make these changes to their facilities.</li> <li><strong>Crisis response programs keep people with behavioral health disorders out of jail and increase likelihood of connecting individuals to care, but are implemented inconsistently across the country.</strong> When employed appropriately, specially trained crisis response teams can reduce the risk of serious injury or death during an emergency interaction between individuals with behavioral health disorders and police officers. However, many crisis intervention programs operate through volunteer efforts, which limit their reach. To be most effective, crisis response programs need funding to equip providers with evidence-based training, safety equipment and ways to link individuals to appropriate clinical and social resources.</li> <li><strong>Significant barriers remain for the adoption of EHRs by behavioral health providers.</strong> The 2009 HITECH Act incentivized EHR adoption with payments for providers who participate in the Medicare and Medicaid Promoting Interoperability Programs; however, psychiatric hospitals are ineligible for these programs. In addition to this financial pressure, the nature of behavioral health records — that is, that they are often narrative or follow a different structure than physical health records — as well as conflicting regulatory requirements regarding information sharing has led to far lower adoption of EHRs in psychiatric hospitals compared to general acute care hospitals.</li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> <div><a href="/topics/access-behavioral-health" hreflang="en">Access to Behavioral Health</a></div> <div><a href="/topics/behavioral-health-care-delivery" hreflang="en">Behavioral Health Care Delivery</a></div> <div><a href="/topics/legislative" hreflang="en">Legislative</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-behavioral-health-infrastructure-0521.pdf" type="application/pdf; length=55366" title="Fact Sheet: Federal Investment in Behavioral Health Infrastructure Needed to Address Mounting Crisis">Fact Sheet: Federal Investment in Behavioral Health Infrastructure Needed to Address Mounting Crisis PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:53:36 +0000 Matthew Diener 677544 at https://www.aha.org Fact Sheet: Federal Investment Needed to Keep Hospitals’ Physical Infrastructure Ready to Meet Health Care Needs https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-federal-investment-needed-keep-hospitals-physical-infrastructure <span class="title">Fact Sheet: Federal Investment Needed to Keep Hospitals’ Physical Infrastructure Ready to Meet Health Care Needs</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:48 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>To deliver the safe, timely and effective care that Americans depend upon, hospitals, health systems, behavioral health and post-acute care providers continually maintain over 6,000 hospitals, nearly 920,000 hospital beds and thousands more clinics. This physical infrastructure also relies on a vast array of complex and costly mechanical systems, information technology, medical equipment and other supplies. America’s hospital infrastructure also must be prepared to function under a daunting array of circumstances. From routine care and medical emergencies to pandemics and natural disasters, hospitals must operate 24 hours per day, 7 days per week. In doing so, they also must meet federally mandated quality and safety standards that continually evolve to keep up with advances in clinical practice.</p> <p>However, America’s hospital infrastructure is at an inflection point. Hospitals are highly vulnerable to rapidly emerging challenges, including aging physical plant, severely deteriorated hospital finances, new quality standards and advances in diagnostic and therapeutic technologies. While hospitals are doing everything within their ability to respond, the scope, scale and urgency of these challenges means they cannot adequately maintain and upgrade the hospital infrastructure Americans need and deserve without federal financial support.</p> <p>The federal government has a history of providing dedicated funding for the modernization of America’s hospital infrastructure. For over 50 years (from 1946-1997), the Hill-Burton Act provided hospitals and other health care facilities with access to grants and loans for facility construction and modernization. Many hospitals need support so they can update their facilities and remain an access point to care in their communities, especially those hospitals serving medically underserved populations. In addition, investments in hospital infrastructure also are investments in the people and communities they serve. Hospitals and health systems often are economic anchors supporting 1-out-of-9 jobs in the U.S., and over $1 trillion in purchases of goods and services from others in their community.</p> <p>Moreover, COVID-19 has revealed that our health care infrastructure was under-resourced for a pandemic. Many hospitals and health systems were financially challenged headed into the crisis and now are experiencing unprecedented financial losses. Nearly four dozen hospitals have closed or declared bankruptcy in the past year. Furthermore, continual cost pressures have left hospitals with very little excess capacity, which became apparent during surges in COVID-19 that resulted in scarce inpatient and ICU beds. Now is the time to invest in our health care infrastructure to ensure we will be fully equipped for any future public health emergency, whether it be a new virus, a mass shooting or a natural disaster. Finally, given the increase in extreme weather events – including floods, fires and hurricanes – now also is the time to assist hospitals in making modifications to their facilities to ensure they can remain resilient and deliver care to their communities.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to prioritize funding for America’s hospital infrastructure. These investments are critical to ensuring the long-term sustainability and viability of hospitals, and maintaining access to high quality, safe and environmentally sustainable health care.</strong></p> <h2>Why?</h2> <ul> <li><strong>Investment in hospital infrastructure is an investment in American jobs and communities.</strong> Hospitals and health systems are often economic anchors that create jobs and purchase goods and services from others in their community. For example, in 2019 hospitals: employed more than 6 million individuals in full- or part- time positions; purchased more than $1 trillion in goods and services from other businesses; supported almost 18 million, or one out of nine, jobs; and supported roughly $2.30 of additional business activity in the economy for every dollar they spent.</li> <li><strong>Hospital physical plant is aging, and unprecedented financial losses caused by the COVID-19 pandemic severely jeopardize the ability of hospitals to afford the maintenance and upgrades they need.</strong> The AHA projected that hospital and health system losses were expected to be at least $323.1 billion through 2020. These losses are expected to continue into 2021, as <a href="/system/files/media/file/2021/02/KH-2021-COVID-Impact-Report_FINAL.pdf">KaufmanHall projects</a> revenue losses to be between $50 and $120 billion in 2021, and the percentage of hospitals with negative operating margins could be higher at the end of 2021 (nearly half, under pessimistic scenarios) than prior to the pandemic. During the pandemic, Americans delayed or postponed care while hospital expenses increased. For example, 2020 prescription drug expenses increased 17% over 2019. Expenses for labor, purchased services and supplies also increased significantly in 2020. Taken together, these impacts have caused many hospitals to pause capital spending, thereby delaying necessary maintenance even further.</li> <li><strong>Financial challenges threaten to dampen many hospitals’ ability to borrow the money they need to finance needed infrastructure repairs and upgrades.</strong> Key credit rating agencies Moody’s Investor Service and Standards &amp; Poor (S&amp;P) view the hospital and health sector as negative in 2021. Moreover, S&amp;P found that the majority of rating revisions in 2020 were downward, which reflects the historic financial pressure the pandemic exerted on hospitals and health systems. Credit rating agencies are an important indicator of hospitals’ and health systems’ access to capital as they tell us about hospitals’ ability to access capital, and the cost of borrowing. Loss of revenue and increased expenses has caused some hospitals to spend from their reserves, and many lack the financial cushion they had prior to the pandemic. This means less funding available for infrastructure investments.</li> <li><strong>Hospitals that may be in most need of infrastructure upgrades also may have the greatest challenges accessing capital.</strong> For example, nearly one-third of rural hospitals reported an average age of plant of 15 years or older. Rural hospitals already faced enormous financial challenges leading up to and during the pandemic, with 136 rural hospitals having closed since 2010, including a record high of 20 in 2020 alone. Those challenges will only persist in 2021. Kaufman Hall estimates that under even the most optimistic scenarios, rural hospitals are likely to end 2021 with margins 38% lower than pre-pandemic levels.</li> <li><strong>Hospital “slack” capacity to respond to public health emergencies is limited.</strong> Ongoing changes to our health care payment system have placed continual pressures on hospitals to reduce inpatient bed capacity. Indeed, total hospital beds in the U.S. have declined by 33% since 1980. The U.S. also has fewer beds per person than similar countries, and lower hospital density than almost all similar countries. Furthermore, as evidenced by supply chain challenges at the beginning of the COVID-19 pandemic, hospitals have had to make their reserve capacity of important supplies and equipment very lean.</li> <li><strong>Hospitals are uniquely vulnerable to the increasing severity and frequency of extreme weather events.</strong> Extreme weather events like floods, wildfires, tornadoes and hurricanes compromise not only the physical integrity of hospitals, but also that of the broader infrastructure on which they depend, such as the power grid. Hospitals could use federal support for projects like improved onsite backup power generation, enhanced window and roof wind shear ratings and water-tight sealing of lower levels. These could help facilities avoid debilitating damage, both financially and structurally, and allow hospitals to continue to meet the needs of their community during and after catastrophic weather events.</li> <li><strong>Long under-addressed behavioral health needs will be exacerbated due to the COVID-19 crisis; hospitals need to increase capacity and offer specific services and facilities to meet these needs.</strong> One in three adults reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019; however, over 100 million Americans live in areas that have a shortage of mental health professionals. Before the pandemic, nearly 60% of adults with behavioral health disorders reported not receiving services for their conditions. While some individuals have been able to access care via telehealth during the pandemic, hospitals will struggle to sustain and expand offerings that meet the large scale and severity of America’s behavioral health care needs. Children and adolescents in particular face critical care shortages, especially because of their unique needs. To address behavioral health issues, hospitals need support to provide safe facilities with appropriate equipment and tailored services – which are widely under-reimbursed, and thus challenging to maintain. This will include procuring appropriate end-user audio-video equipment, building remote clinics, and installing interoperable electronic health records to improve information sharing.</li> <li><strong>Hospitals are interested in improving the environmental sustainability of their own operations but will need support and regulatory modernization.</strong> As essential infrastructure, hospitals consume a significant amount of energy due to factors such as their continual operations, need for high-energy diagnostics, and high ventilations rates for airborne infection prevention. Many hospitals are taking steps to become more energy efficient, including renovating electrical systems, retrofitting more energy efficient technology, installing solar panels, or procuring from more sustainable sources. Many hospitals also are considering new ways to manage the waste they produce, such as improving recycling programs. These steps often come with significant cost, at a time when hospitals are still experiencing financial pressure due to the COVID-19 pandemic. Furthermore, it will be important to modernize regulations to ensure that the hospitals that are ready to implement environmentally friendly changes are not constrained by outdated regulations.</li> <li><strong>Evolving quality and safety standards can benefit patients, but often are impossible to meet without significant and costly changes to hospital physical plant. Key examples include:</strong> <ul> <li><em>Infection Control Safety.</em> As the COVID-19 pandemic has highlighted, identifying and isolating infectious disease in a health care setting is critically important. To properly identify cases and limit transmission, investment in infection control infrastructure like isolation units, negative pressure rooms, digital communications platforms and medical surveillance are necessary to ensure hospitals are able to appropriately respond to and meet the health demands that result from the presence of infectious disease.</li> <li><em>Pharmacy Upgrades.</em> As more-advanced medications are developed, full-scale renovations of hospital compounding pharmacies – including with new ventilation, waste disposal systems and negative pressure rooms – often are necessary to ensure the safety of both health care personnel preparing and administering the drug, as well as the patients receiving the treatment.</li> <li><em>Ongoing Regulatory Compliance.</em> Medicare’s Conditions of Participation (CoPs) and associated guidance have evolved rapidly, and costly changes abound. For example, behavioral health hospitals and units have had to upgrade doors and beds to adhere to the latest suicide prevention standards. Moreover, hospitals have had to shift entryways and exits in those facilities that are co-located with another entity.</li> </ul> </li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> <div><a href="/topics/legislative" hreflang="en">Legislative</a></div> <div><a href="/topics/advocacy-public-policy" hreflang="en">Advocacy &amp; Public Policy</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-physical-infrastructure-0521.pdf" type="application/pdf; length=59077" title="Fact Sheet: Federal Investment Needed to Keep Hospitals’ Physical Infrastructure Ready to Meet the Nation’s Health Care Needs">Fact Sheet: Federal Investment Needed to Keep Hospitals’ Physical Infrastructure Ready to Meet Nation’s Health Care Needs PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:48:34 +0000 Matthew Diener 677546 at https://www.aha.org Fact Sheet: Strengthening the Health Care Workforce https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-strengthening-health-care-workforce <span class="title">Fact Sheet: Strengthening the Health Care Workforce</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:32 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>A talented, qualified, engaged and diverse workforce is at the heart of America’s health care infrastructure. Yet COVID-19 has taken a heavy toll on health care teams who have been on the front lines of the pandemic with many suffering from stress, trauma, burnout and increased behavioral health challenges. A 2021 Washington Post-Kaiser Family Foundation survey found that nearly 30% of health care workers are considering leaving their profession altogether, and nearly 60% reported impacts to their mental health stemming from their work during the COVID-19 pandemic.</p> <p>However, the daunting challenge of sustaining the health care workforce predates the COVID-19 pandemic. Recent studies show that America will face a shortage of up to 122,000 physicians by 2032, and will need to hire at least 200,000 nurses per year to meet increased demand and to replace retiring nurses. There also are critical shortages of allied health and behavioral health professionals, especially in vulnerable rural and urban communities. These potential workforce shortfalls – combined with an aging population, a rise in chronic diseases and behavioral health conditions, and advancements in the “state-of-the-art” of care delivery – all contribute to the need for supportive policies that ensure America’s health care workforce can meet the demands of today and be adequately prepared for the delivery system of tomorrow.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to prioritize funding for the infrastructure that supports the health care workforce needs of the country in the wake of the COVID-19 pandemic and into the future.</strong></p> <h2>Why?</h2> <ul> <li><strong>The health care workforce creates American jobs, serves American communities and spurs American economic activity.</strong> Indeed, hospitals and health systems alone employed more than 6 million individuals in full- or part-time positions in 2019; purchased more than $1 trillion in goods and services from other businesses; supported almost 18 million, or one out of nine, jobs; and supported roughly $2.30 of additional business activity in the economy for every dollar they spent. Yet the pandemic is taking its toll on health care jobs. According the U.S. Bureau of Labor Statistics, employment in the field is still down by over 500,000 jobs since February 2020, with hospitals reporting a drop of employment of 5,800 jobs just between March 2021 and April 2021.</li> <li><strong>Physician shortages are growing, exacerbated by caps on the number of Medicare-funded residency slots.</strong> The Association of American Medical Colleges projects a national shortage of up to 122,000 physicians by 2032, including shortages of primary care physicians and specialists such as pathologists, neurologists, radiologists and psychiatrists. While the aging of the U.S. population and the physician workforce drives some of the projected shortage, much of it stems from the caps on Medicare-funded residency slots imposed by Congress nearly 25 years ago as a cost-saving measure. While the number of medical school graduates has increased significantly over the past two decades, training opportunities for these graduates has remained frozen at 1996 levels. As a result, over 3,100 applicants lacked residency slots in 2019. Furthermore, the caps have created imbalances that favor allocation of slots toward lower-cost and higher-reimbursement specialties, rather than more urgently needed primary care and behavioral health. While some hospitals are filling in gaps by self-funding a portion of their residency slots, this model is not sustainable over the long haul, as evidenced by the -9.6% Medicare margins for teaching hospitals in 2018.</li> <li><strong>Lifting the Medicare residency slot cap would enhance access to care and help America’s hospitals better meet the needs of the communities they serve.</strong> Increasing Medicare-funded residency slots would provide hospitals more flexibility to diversify and maintain more training programs, including both primary care and specialty programs. For health systems, an increase in cap slots also would allow for bringing residents to more diverse types of facilities, including those in rural areas, which may not be able to operate their own training programs. This would benefit both the quality of physician education, and the facilities they would serve. In the Consolidated Appropriations Act, 2021, Congress created 1,000 new residency positions. Now is the time to build on that foundation and help alleviate the nation’s critical physician shortage.</li> <li><strong>The nursing and allied professional workforce also faces critical shortages.</strong> The U.S. needs more than 200,000 new registered nurses (RNs) each year to meet increasing health care needs and to replace nurses entering retirement. In 2017, more than half of all nurses were age 50 or older, and almost 30% were age 60 or over. Workforce pressures also exist across a variety of allied health professions. According to one recent survey, the annual turnover rate of hospital certified nursing assistants (CNAs) was 27.7% (nearly double the turnover rate of nurses and physician assistants). Meanwhile, the Bureau of Labor Statistics projects a need for 11% more CNAs by 2025. The lack of laboratory technicians may be particularly acute – a 2017 survey conducted by the American Society for Clinical Laboratory Science concluded that there were, nationally, 7.2% lab technician positions unfilled.</li> <li><strong>Faculty shortages constrain ability to meet future nursing needs.</strong> According to the American Association of Colleges of Nursing, American nursing schools turned away over 80,000 qualified applicants from baccalaureate and graduate programs in nursing due to an insufficient number of qualified faculty, clinical sites, classroom space, clinical preceptors and budget constraints. The low salaries for nursing faculty also are not commensurate with their level of educational preparation (i.e., master’s degree level, or above), making recruitment a dire challenge.</li> <li><strong>America’s behavioral health needs are reaching a crisis point rising amid gaps in the behavioral health workforce.</strong> One in five American adults had a behavioral health condition before the pandemic, and nearly 60% of adults with behavioral health disorders reported not receiving services for their conditions. The stresses of the COVID-19 pandemic have compounded these concerns: one in three adults reported symptoms of an anxiety disorder in 2020, compared with one in 12 in 2019. Yet, over 100 million Americans live in areas that have a shortage of psychiatrists, as designated by the Health Resources and Services Administration (HRSA). HRSA also projects shortages of <a href="https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf" target="_blank">psychiatrists</a> and addiction <a href="https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf" target="_blank">counselors</a> to persist through 2030.</li> <li><strong>Several mechanisms provide good starting points for addressing workforce and faculty shortages.</strong> For example, the AHA supports Congress funding HRSA’s title VII and VIII programs, including, $517 million for the health professions program, continued funding for the National Health Service Corps, and $530 million for the nursing workforce development program, which includes loan programs for nursing faculty. Congress also should consider expanding the loan program for allied professionals. Moreover, Congress should direct any support for community college education to high priority shortage areas in the health care workforce.</li> <li><strong>Rising clinician burnout – accelerated by the pandemic – calls for national support.</strong> A recent National Academy of Medicine report suggests that between 35% and 54% of U.S. nurses and physicians have symptoms of burnout, which it characterizes as high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work. Hospitals and health systems are deploying a range of programs and interventions to assist their workforce, but given the financial pressures posed by the pandemic, Congress should provide additional funding to support national research and demonstration programs related to clinician well-being.</li> <li><strong>Visa relief – especially during the pandemic – is critical given that many hospitals rely on foreign-born employees to serve their communities.</strong> Recent studies show that 18.2% of U.S. health care workers were born outside of the U.S. For example, 29% of U.S. physicians are born in other countries, and almost 7% are not U.S. citizens. Similarly, foreign-born nurses account for 15% of RNs in the U.S., according to a report by the Institute for Immigration Research at George Mason University. That is why the AHA supports the bipartisan Healthcare Workforce Resilience Act, which would expedite the visa authorization process for highly-trained nurses who could support hospitals facing staffing shortages, and provide protections to U.S.-trained, international physicians who are vitally important to patient care in their communities, but whose visa status puts them at heightened risk should they get sick.</li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> <div><a href="/topics/workforce" hreflang="en">Workforce</a></div> <div><a href="/topics/advocacy-public-policy" hreflang="en">Advocacy &amp; Public Policy</a></div> <div><a href="/topics/legislative" hreflang="en">Legislative</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-workforce-infrastructure-0521.pdf" type="application/pdf; length=59924" title="Fact Sheet: Strengthening the Health Care Workforce">Fact Sheet: Strengthening the Health Care Workforce PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:32:19 +0000 Matthew Diener 677550 at https://www.aha.org Fact Sheet: Ensuring Hospital Infrastructure Meets the Nation’s Needs Today and Into the Future https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-ensuring-hospital-infrastructure-meets-nations-needs-today-and <span class="title">Fact Sheet: Ensuring Hospital Infrastructure Meets the Nation’s Needs Today and Into the Future</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:30 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>Americans rely on hospitals to care for them when they are sick and injured and to help them improve and maintain their health. As evidenced by the COVID-19 pandemic, hospitals are where Americans turn in times of disaster and emergency – the blue “H” represents safety, security and healing at all hours of every day.</p> <p>To be there for a community, hospitals require a vast constellation of physical, technological, and human infrastructure – from brick-and-mortar buildings to the highest skilled clinical workforce to digital connectivity. Over the past decade, groundbreaking technological advancements have paved the way for new, more effective ways to deliver care, yet many hospitals lack the physical capacity and skilled workforce to utilize these new tools. <strong>That is why it is imperative that Congress invest in America’s hospitals and health systems to ensure that the nation’s health care needs can be met today and into the future.</strong></p> <p>Advancements in technology, changes in the U.S. workforce and the evolution of the U.S. economy have created the need to modernize how the term “infrastructure” is perceived. There is no better example of organizations that are necessary to the growth of other businesses and to improved quality of life than America’s hospitals and health systems. Hospitals and health systems are steadfast in their mission to serve their communities, not just through the provision of vital health care services, but through public health and education initiatives and as economic engines that provide good-paying jobs and support local businesses in every congressional district across the country.</p> <p>Recognizing the unique and foundational role hospitals play requires an understanding that each component of a modern infrastructure package – from increased access to broadband and physical infrastructure improvements to workforce training and updates to emergency preparedness programs – are interwoven and must work together to realize the full benefit. When considering what infrastructure encompasses, it is necessary to include America’s hospitals and health systems in that conversation. Simply put, an investment in the infrastructure of our nation’s health care system is a direct investment in the physical, mental and economic health of our country, without which communities across the U.S. will not be able to fully enjoy the other investments in infrastructure currently being considered.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to prioritize funding for America’s hospital infrastructure. These investments are critical to ensure the overall health and security of our country, the long-term sustainability and viability of hospitals, and the wellbeing of patients and communities.</strong></p> <p><strong>The AHA specifically urges Congress and the Administration to:</strong></p> <ul> <li><strong>Invest in Hospital Physical Infrastructure</strong></li> <li><strong>Strengthen the Health Care Workforce</strong></li> <li><strong>Build Capacity for Emergency Preparedness and Response</strong></li> <li><strong>Expand the Digital and Data Infrastructure for Health Care</strong></li> <li><strong>Secure the Health Care Supply Chain</strong></li> </ul> <h2>Why?</h2> <ul> <li><strong>Investment in hospital infrastructure is an investment in American jobs and communities.</strong> Hospitals and health systems are economic anchors that create jobs and purchase goods and services from others in their community. In 2019, hospitals employed more than 6 million individuals in full- or part-time positions; purchased more than $1 trillion in goods and services from other businesses; supported almost 18 million, or one out of nine, jobs; and generated roughly $2.30 of additional business activity in the economy for every dollar they spent.</li> <li><strong>Hospital physical plants need to be modernized to maintain access to high quality, safe and environmentally sustainable health care.</strong> America’s hospital infrastructure is highly vulnerable to several rapidly emerging challenges. Hospitals and health systems also have been hit hard financially due to the COVID-19 pandemic. Hospitals’ losses were expected to be at least $323 billion through 2020, and significant losses are expected to continue into 2021, with key credit rating agencies viewing the hospital and health sector as negative. This results in significant challenges accessing capital.</li> <li><strong>A strong workforce is the foundation of our nation’s health care infrastructure.</strong> A qualified, engaged, diverse workforce is the core infrastructure of our health care system. Yet COVID-19 has taken a heavy toll on our health care heroes who have been on the front lines of the pandemic, with many suffering from trauma, burnout and increased behavioral health challenges. A number of hospitals have experienced critical staffing issues due to the demands of surges of very ill COVID-19 patients, as well as needing assistance in helping control the pandemic through testing, contact tracing and vaccine deployment. Additionally, practitioners are choosing to retire early given the strain of the past year.</li> <li><strong>The nation needs to build capacity for emergency preparedness and response.</strong> When a disaster hits, people turn to hospitals for help. Congress created the Hospital Preparedness Program (HPP) after 9/11, but its funding has not kept pace with needs, and monies are often siphoned off by the state – never making it to the intended recipient of hospitals. These funds are critical to ensure infrastructure support and flexibility hospitals need to respond to a public health emergency. During the COVID-19 pandemic, hospitals have had to “reinvent” their physical structure, such creating bed capacity, separate COVID-19 and non-COVID-19 wings/entrances, new airflow and ventilation, and adjusted medication handling and distribution.</li> <li><strong>A robust health care digital and data infrastructure is necessary to address key gaps in access, quality and equity.</strong> The COVID-19 emergency highlights the importance of a strong digital health infrastructure. This includes access to adequate, affordable broadband connectivity, which is essential to enabling telehealth and increasing access to care, as well as support for telehealth infrastructure to ensure all Americans, particularly those in underserved communities, can realize the promise of digital health. Additionally, we must prioritize strong cyber defenses to protect the privacy and safety of patients and their health information. Finally, we must continually modernize the key data systems that support the ability of government and health care organizations to identify, track and respond to issues that affect health equity, racial and ethnic disparities, the quality of health care delivery and public health responses.</li> <li><strong>Supply chain reliability is critical to protecting patient care.</strong> A strong medical supply chain is critical to delivering safe and effective high-quality care to patients; however, it has become increasingly clear that the level of fragility across our national medical supply chain is unsustainable. A disruption anywhere in the supply chain process has the potential to create a series of prolonged difficulties in supply acquisition for providers, which ultimately can directly affect the patients they treat, or even their ability to offer treatment. To mitigate these challenges, investment in strengthening the supply chain is crucial. In addition, a focus on increasing domestic production capacity and manufacturing redundancy, while reinforcing the strategic national stockpile (SNS), will provide significant improvements for providers and patients.</li> <li><strong>Investment in the physical, workforce and digital infrastructure related to behavioral health services is crucial.</strong> Behavioral health needs have long gone under-addressed in the U.S., and the COVID-19 pandemic has and will continue to exacerbate this issue. For example, the Centers for Disease Control and Prevention reported that overdose deaths spiked after the start of the pandemic, driven by synthetic opioids like fentanyl. It is essential that hospitals and health systems are able to serve patients experiencing mental illness and/or substance use disorders both in-person and remotely, and that the capacity to respond to the unique behavioral health needs of children and adolescents is expanded. Inpatient psychiatric facilities, as well as general acute care hospitals that offer inpatient and outpatient behavioral health programs like partial hospitalization and opioid treatment programs, face unique infrastructure challenges that are critical to address now before the increasing surge of behavioral health needs stemming from the pandemic becomes insurmountable.</li> <li><strong>Hospitals are interested in improving the environmental sustainability of their own operations but will need support and regulatory modernization.</strong> As essential infrastructure, hospitals consume a significant amount of energy due to factors such as their continual operations, need for high-energy diagnostics, and high ventilations rates for airborne infection prevention. Many hospitals are taking steps to become more energy efficient, including renovating electrical systems, retrofitting to moreenergy-efficient technology, installing solar panels, or procuring from more-sustainable sources. Many hospitals also are considering new ways to manage the waste they produce, such as improving recycling programs. These steps often come with significant cost at a time when hospitals are still experiencing financial pressure due to the COVID-19 pandemic. Furthermore, it will be important to modernize rules to ensure hospitals that are ready to implement environmentally friendly changes are not constrained by outdated regulations.</li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-infrastructure-needs-overview-0521.pdf" type="application/pdf; length=56223" title="Fact Sheet: Ensuring Hospital Infrastructure Meets the Nation’s Needs Today and Into the Future">Fact Sheet: Ensuring Hospital Infrastructure Meets the Nation’s Needs Today and Into the Future PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:30:28 +0000 Matthew Diener 677541 at https://www.aha.org Fact Sheet: Federal Investment Needed to Strengthen the National Medical Supply Chain https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-federal-investment-needed-strengthen-national-medical-supply <span class="title">Fact Sheet: Federal Investment Needed to Strengthen the National Medical Supply Chain</span> <span class="uid"><span>Matthew Diener</span></span> <span class="created">May 27, 2021 - 08:22 AM</span> <div class="body"><div class="container"> <div class="row"> <div class="col-md-8"> <h2>The Issue</h2> <p>A strong and reliable medical supply chain is a critical and integral component to delivering safe and effective high-quality care to patients; however, it has become increasingly clear that the level of fragility across our national medical supply chain is unsustainable and poses significant risk to hospitals and health systems, as well as the patients and communities they serve.</p> <p>Hospitals rely on the effectiveness of the various groups that make up the supply chain, including manufacturers, sterilizers, distributors and, in many cases, group purchasing organizations (GPOs). A disruption anywhere in the process has the potential to create a series of prolonged difficulties in supply acquisition for providers, which ultimately can directly affect the patients they care for, or even their ability to offer treatment at all. These disruptions can be the result of poor oversight, bad actors, policy initiatives and political motivations, as well as unforeseen and unpredictable events, like the COVID-19 pandemic or severe weather events.</p> <p>Exacerbating these difficulties is the “lean” or “just-in-time” framework in which the medical supply chain currently operates, meaning there is effectively very little buffer when disruptions occur. Health care providers, distributors and manufacturers have pursued this just-in-time supply chain approach to lower costs so that health care is more affordable, but the pandemic has made clear the risks of such a strategy. When those disruptions occur, providers have little-to-no notice and can be left scrambling to acquire products necessary to perform the core functions of providing health care.</p> <p>To mitigate these challenges, investment aimed at strengthening the supply chain is crucial. A focus on increasing manufacturing redundancy, diversifying where raw materials are produced and where products are manufactured and “fattening” the overall supply chain will provide significant improvements. Hospitals and the communities they serve rely on adequate access to life-saving supplies and medications, and without substantial steps to strengthen the current framework, future health emergencies will result in the same shortfall our country recently experienced.</p> <h2>AHA Take</h2> <p><strong>The AHA urges Congress and the Biden Administration to take steps to strengthen the nation’s medical supply chain. America’s hospitals and health systems rely on the efficient and timely delivery of supplies so they in turn can deliver safe and effective care, especially in times of emergency. We support increased investments to maintain consistent and continuous access to medical supplies for hospitals and our entire health care system.</strong></p> <h2>Why?</h2> <ul> <li><strong>Diversify manufacturing sites as well as sources of critical raw materials to ensure supply chain sustainability.</strong> Currently, the U.S. relies heavily on both China and India for the raw materials necessary to manufacture medical devices and pharmaceutical products. Further, many manufacturers of these products utilize manufacturing facilities located in both China and India. The overwhelming reliance on a limited number of countries for the equipment and pharmaceutical products necessary to care for patients in the U.S. raises serious concerns and poses significant risks to patients and health care workers alike should a disruption occur. Congress and the Biden Administration should encourage redundancy in the supply chain through policy initiatives focused on spurring diverse sites of production, including where possible, onshore manufacturing of critical active pharmaceutical ingredients and products.</li> <li><strong>Support advancements in reuse and reprocessing technologies to mitigate supply challenges while decreasing waste and environmental impact.</strong> The COVID-19 pandemic required providers and manufacturers to adapt quickly to minimize the impact of supply shortages on patients. Several adaptations warrant additional consideration and investment to strengthen the supply chain for the future. For example, efforts to reuse or repurpose certain medical devices, like respirator masks, proved critical when supply was scarce. Continued investments in these technologies can help providers navigate future supply shortages while also decreasing the amount of waste associated with the production and discarding of traditional single-use devices.</li> <li><strong>Invest in new product development.</strong> Opportunities exist to incentivize the development of new products that can be manufactured without raw materials sourced in the U.S., thus increasing the reliability and long-term sustainability of our domestic supplies. Additionally, investments in virtual inventory technology programs that function as supply “control towers” could ensure more accurate product visibility and aid in efforts to identify when supply capacity is approaching demand.</li> <li><strong>Develop and adapt certain data standards to aid in early detection and mitigation of supply shortages.</strong> Disruptions to the supply chain can force hospitals and health systems to cancel non-emergent procedures or delay non-emergent care due to a lack of critical supplies meant to keep both health care workers and their patients safe. In those instances, increased adoption of certain data standards, like the Unique Device Identifier (UDI), can enhance inventory management, transparency and the early detection of supply shortages with the goal of resolving the issue before it significantly affects patient care. Further, investments in the purchase of product scanning technology at the point of use can allow providers to quickly assess utilization, recognize upcoming shortages and take steps to resolve them. Increased adoption of both the UDI and scanning technologies will improve multi-directional information sharing and data analytic capabilities across the health care supply chain.</li> <li><strong>Increase end-user inventories and incentivize additional cushion.</strong> The current just-in-time approach to supply chain logistics functions is outdated. The COVID-19 pandemic highlights the real risks this process has posed to patient and health care worker safety, and the provision of vital hospital services. Steps need to be taken to “feed” the supply chain with the goal of ensuring enough product is available, or capable of being made available, when demand increases. For example, supporting an increase in end-user inventory of critical supplies and medications across the existing manufacturing and distribution infrastructure in the U.S. will help add necessary capacity to the existing supply chain. Further, these actions will decrease the need for large national and state stockpiles, which can be difficult to manage and maintain and present significant operating cost, product expiration and waste issues. Finally, efforts to increase on-hand inventory for end-users allows manufacturers and distributors to increase production capacity, while also putting providers in a position to have enough access to supply in instances where demand spikes but additional measures like the Defense Production Act have not yet been invoked.</li> </ul> </div> <div class="col-md-4"> <center> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/action-alert/2021-05-25-urge-your-senators-representatives-include-resources-support-hospitals-and" target="_blank">Action Alert: Urge Your Senators, Representatives to Include Resources to Support Hospitals and Health Systems in Upcoming Infrastructure Legislative Package</a></div> </center> </div> </div> </div> </div> <div class="field_topics"> <div><a href="/topics/infrastructure" class="topic" hreflang="en">Infrastructure</a></div> <div><a href="/topics/supply-chain-management" hreflang="en">Supply chain management</a></div> <div><a href="/topics/advocacy-public-policy" hreflang="en">Advocacy &amp; Public Policy</a></div> <div><a href="/topics/legislative" hreflang="en">Legislative</a></div> </div> <div class="field_type"> <div>Type</div> <div><a href="/type/fact-sheets" hreflang="en">Fact Sheets</a></div> </div> <div class="field_paragraphs_text_with_heade"> <div> <div class="paragraph paragraph--type--paragraphs-text-with-headers- paragraph--view-mode--default"> </div> </div> </div> <div class="field_search_promotion"> <div>Search Promotion</div> <div>Not Promoted</div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="https://www.aha.org/system/files/media/file/2021/05/fact-sheet-supply-chain-infrastructure-0521.pdf" type="application/pdf; length=51960" title="Fact Sheet: Federal Investment Needed to Strengthen the National Medical Supply Chain">Fact Sheet: Federal Investment Needed to Strengthen the National Medical Supply Chain PDF</a></span> </div> </article> </div> </div> <div class="field_archived"> <div>Archived</div> <div>Off</div> </div> Thu, 27 May 2021 13:22:55 +0000 Matthew Diener 677549 at https://www.aha.org