Hospitals are anchor institutions in Washington State communities, providing both needed services to patients 24 hours a day, 7 days a week, 365 days a year and stable jobs for health care professionals. The Washington State Hospital Association (WSHA) strives to ensure that all our state’s communities have access to high-quality health care. Given that the 2020 session will be a short one (60-days in regular session) and there will be limited new revenue for budget issues, the following document represents WSHA’s priorities.
WSHA’s legislative agenda supports the following principles:
- Ensure patients have access to care during and after hospitalization
- Ensure hospitals can be stable institutions serving their communities, long into the future
- Maintain flexibility for hospital operations while preventing burdensome and costly new regulations
Policy Priorities (not in order of priority)
Ensure patients have access to care during and after hospitalization
- Ensure Medicaid patients get the post-acute care they need for timely discharge from the hospital (WSHA bill/Support). Medicaid patients are stuck in hospitals for unnecessary days because the state cannot determine post-acute placement in a timely manner. This is not right for patients. The Department of Social and Health Services (DSHS) CARE Assessment process to assess a patient’s care needs and the rate the state will pay a post-acute care setting takes more than a month to complete. Too often, the process takes even longer because community providers cannot accept the low payment rate and the exception process does not work. WSHA supports the following:
- Improve the assessment tool and exception process. The state should examine its historical data on the CARE assessment process, including appeals, to recommend process and outcome improvements.
- Allow presumptive eligibility for long-term services and supports. Presumptive eligibility would allow patients to be assessed for functional and financial eligibility quickly to support timely discharge from the hospital. DSHS staff would then conduct a full CARE assessment to verify the initial determination.
- Allow hospital employees to conduct the functional pre-assessment portion of the CARE assessment. Currently, only DSHS employees may conduct any part of the CARE assessment. Given the high workloads of these employees, hospital employees with knowledge of the patient’s needs and condition should conduct the pre-functional portion of the assessment with quality control by DSHS.
- Adopt appropriate storage and retention standards for unreported sexual assault kits for survivors (Support). WSHA supports clear standards in law for storage location, retention duration, notice and destruction procedures for unreported sexual assault kits that support the needs of survivors. While hospitals are critical partners in the collection of sexual assault evidence, they do not have room to store assault kits for long periods of time while assuring the standards are met for criminal prosecution. Therefore, WSHA supports funding for a solution that relies on law enforcement or the state’s Crime Lab to allow proper storage – in a single location – for all elements of an unreported sexual assault kit.
- Support home nursing services in rural areas (WSHA bill/Support). Rural and remote areas of Washington State lack adequate access to home health services. Federal law allows rural health clinics (RHCs) to request designation of a home health shortage area by the Department of Health with approval from the Centers for Medicare and Medicaid Services (CMS). This designation allows RHCs to offer a limited scope of services, including home nursing visits to homebound patients. Under current state law, RHCs would need to be licensed as a home health agency and be granted a Certificate of Need (CN) in order to provide this service. WSHA supports legislation that provides an exemption from both the licensing and CN requirements for rural health clinics within a designated shortage area.
Ensure hospitals can be stable institutions serving their communities, long into the future
- Evaluate a federal rural payment model (Evaluate proposal). There is some interest in the legislature to “transform” rural health delivery and financing. We are waiting to see whether a new payment model from CMS will be helpful for some communities. The specifics are not yet clear, but WSHA supports reasonable guardrails for the model at the state level, such as voluntary participation. WSHA has developed guiding principles that will be used to evaluate any proposal. One concerning issue is that some hospitals don’t have a lot of inpatient services and legislators are questioning the need for the hospital. The hospital infrastructure is critical to ensure access to primary and behavioral health care and nursing home beds.
- Ensure payment from MCOs for services provided to patients by substitute providers or ‘locums’ (WSHA bill/Support). Hospitals and clinics often use substitute providers to ensure continuous access to care for patients when the usual provider takes a leave of absence. However, Medicaid managed care organizations (MCOs) often only pay for services provided by these substitute providers for 60 days, unless they are fully credentialed with the plan – a process which can take months. This creates a gap in payment. Further, hospitals and clinics are unable to use substitute providers to stand in for retiring providers or while they are recruiting for a permanent position. A new state law should require Medicaid MCOs to reimburse hospitals and rural providers for services provided by substitute providers regardless of how long the credentialing process takes and allow for substitute providers when recruiting for an open position. These changes would ensure seamless access to care for patients served by Washington’s small and rural hospitals and clinics.
- Oppose Qui Tam actions for employment Law violations (Oppose). Washington State has an array of employment laws creating worker protections related to wages, safety, overtime, and leave, among others. State agencies have significant powers to enforce these laws. HB 1965 would authorize people to sue employers for violating these laws on behalf of the state agencies in exchange for a portion of the monetary proceeds. Qui Tam is a powerful legal tool that is ripe for abuse, even with safeguards in place—and HB 1965 contains none. California is the only state with this model and it has led to significant abuse. This is the wrong direction for our state.
- Support telemedicine payment parity and remove restrictions to access (Support). Delivering care through telemedicine increases patient access to essential health services. Payment parity – being paid the same for clinical services provided through telemedicine as for an in-person visit – increases the use of telemedicine services. To provide better patient care, telemedicine use may be increased by removing the requirement that an in-person visit to the referring provider is required before the use of store-and-forward technology will be reimbursed. Store and forward is the process of storing clinical information for later diagnosis and action by the provider. The use of store-and-forward can replace the need for inpatient or outpatient visits for important services such as mental health.
- Ensure that any changes to the Involuntary Treatment Act (ITA) improve patient access to timely and appropriate care (Concerns). The ITA governs the involuntary treatment of persons with serious mental illness and substance use disorders. Any proposed changes, such as expanding criteria for detention or increasing the initial detention period to five days, cannot compromise patient care. If any proposed change will increase patients being detained, including under single-bed certification, the state needs to ensure that hospitals and E&T facilities have adequate resources to care for these vulnerable patients.
- Ensure that freestanding psychiatric hospitals have a reasonable regulatory structure that promotes quality patient care (Evaluate proposal). Freestanding psychiatric hospitals are an important source of behavioral health services across the state. Any regulatory oversight needs to ensure that patient access to high-quality care is the overarching goal.
Maintain flexibility for hospital operations while preventing burdensome and costly new regulations
- Modernize prior authorization requirements for patients and providers (WSHA bill/Support). Hospitals and providers are concerned about the increasing volume and the variation of prior authorization requirements from health insurers, many of which delay patient care for services. WSHA supports a bill to require insurers to submit data to the Office of the Insurance Commissioner information for services requiring prior authorization. The OIC would provide the information to a new work group, which would select specific services for review and recommendations regarding the need for prior authorization, suitability for Appropriate Use Criteria, and selection of uniform criteria. Health insurers, Medicaid, PEBB and SEBB, would be required to adopt the recommendations.
- Ensure new general consumer privacy laws align with existing health privacy protections (Concerns/ Neutral depending on version). WSHA supports efforts to enhance consumers’ access and control of their personal data. Hospitals and health systems maintain stringent privacy and security standards towards these goals, as regulated entities under several state and federal laws, including HIPAA. WSHA has concerns that a general privacy law would mandate new, onerous and conflicting requirements on hospitals. Meaningful exemption language that recognizes these existing standards is required to protect patient safety and public health, and support care coordination and increasing quality of care.
- Protect the quality and safety of care (Neutral/Evaluate proposals). WSHA has significant concerns with a proposal to prohibit hospitals from appropriately managing the types and quality of services provided in their facilities. We support providing patients with information – and a referral where possible and appropriate – to locations that provide care not offered by the hospital.
- Support participation in the nurse licensure compact (Support). Currently, 34 states have joined the Nurse Licensure Compact to increase access to care to qualified nurses while maintaining public protection and state oversight of nurses. It can take several months for nurses to obtain a Washington State license. Under the compact, nurses can practice in other compact states without having to obtain a specific Washington State license – allowing nurses to find employment more quickly and hospitals to hire the staff they need to maintain access to care for patients.
- Ensure reasonable transparency laws (Evaluate proposals). Hospitals report a wide array of financial and clinical information to the state Department of Health, the Centers for Medicare and Medicaid Services and the Internal Revenue Service. Before our state requires more reporting on hospitals, the legislature should be very clear about what pieces of information are not captured currently.
WSHA Budget Asks (In Order of Priority)
- Protect hospitals/health systems from the new Business and Occupation (B&O) tax surcharge. Many large hospitals/health systems will pay the new B&O tax surcharge on physician services and other services that are not provided directly by the hospital. Additionally, some hospital/health systems that do not qualify for the health or social welfare organization deduction are already paying an increased B&O tax. Those hospitals serve high numbers of Medicare and Medicaid patients, which generally pays less than the cost of providing care. WSHA supports maintaining the exemption for hospitals.
- Ensure difficult to discharge patients have placement for memory care. No one should live in a hospital. But some patients are not able to discharge to more appropriate post-acute care settings (such as a skilled nursing facility, adult family home or nursing home). The lack of memory care services for Medicaid patients living with dementia, Alzheimer’s and traumatic brain injury is a significant barrier to post-acute placement for community hospitals. WSHA supports increasing Medicaid long-term care payment rates for these patients. A funding request of about $5 million in state funds; $10 million total with federal funds.
- Support and expand needed mental health care. WSHA asks the legislature to:
- Establish a sustainable rate to ensure 90- and 180-day civil commitment beds in the community. In 2019, the Legislature established a work group to create a per diem payment rate methodology for community hospitals caring for patients on 90- and 180-day civil commitment orders. WSHA has been working with the Health Care Authority on the methodology to ensure that it establishes a sustainable rate, that at a minimum, covers the cost of caring for these complex and vulnerable patients. In 2020, ensure that the Legislature adopts a sustainable payment rate methodology for community hospitals willing to serve this patient population.
- Fund intensive outpatient and partial hospitalization programs for Medicaid mental health patients. These services, currently not authorized by Medicaid, provide patients with mental health services to help prevent hospitalizations or provide intensive services after a hospitalization to avoid readmissions. An intensive outpatient and partial hospitalization program funding request would be effective January 1, 2021 (to allow time to amend the Medicaid state plan and the Medicaid managed care contracts) through June 30, 2021 (the end of the biennium). For intensive outpatient programs, this would be $2.2 million in state funds ($6 million total with federal funds); and for partial hospitalization programs, this would be $2.4 million in state funds ($6.2 million total with federal funds).
Non-WSHA Budget Asks We May Support (In Order of Recommendation)
- Support a federal waiver for Institutes of Mental Disease (IMD). Federal law restricts funding for facilities with more than 16 beds that predominately provide behavioral health services. The Health Care Authority is seeking a waiver from the Center for Medicaid and Medicare (CMS) to address this longstanding problem. ($1 million in state funds, $5 million total with federal funds)
- Support an increase in home health funding. New funding is needed to increase rates for Medicaid patients so that home health agencies can provide needed services across the state.
- Support Title X family planning services. The Department of Health is requesting state funds to replace Title X federal funds because the state is opting out of the family planning program as a result of the White House’s rule on abortion referrals. ($8.4 million in state funds only)
Chelene Whiteaker, Senior Vice President, Government Affairs
Approved by WSHA Board of Directors, December 11, 2019