MHA Today | June 8, 2018

MHA Today: News for Healthcare Leaders

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June 8, 2018

MHA Today is provided as a service to members of the Missouri Hospital Association. Additional information is available online at MHAnet.


Herb Kuhn, MHA President & CEOIn January 2017, MHA released shocking data on the incidence of neonatal abstinence syndrome among Missouri newborns. Reviewing hospital diagnosis codes identifying NAS, researchers found that between 2006 and 2016, NAS increased 538 percent. Even in light of the increased attention to the state and national opioid crisis, the increase was troubling. After the release, front-line clinicians began voicing concern that NAS was underreported.

Earlier this week, MHA released a new policy brief on NAS. First, the researchers endeavored to establish how accurate traditional surveillance was in establishing the scope of NAS in Missouri. Second, the brief provides policy options for mitigating NAS.

For the new report, the Hospital Industry Data Institute began by running traditional surveillance for NAS using the 2017 methodology. Researchers then created a novel approach using two new strategies to explain observed versus coded discrepancies in NAS prevalence. Interestingly, each method delivered significantly different results.

Researchers used traditional surveillance as the baseline. Using conventional surveillance for 2016 and 2017, 1,083 Missouri newborns were identified with a NAS diagnosis.

The two other methods differ by dataset and approach. First, hospital discharge data for opioid-related hospital inpatient and emergency department care for new and expecting mothers were reviewed for nine months before and after birth. Second, a survey of hospital obstetric health providers gleaned observational data, including perceived prevalence and severity of NAS in Missouri obstetrics departments.

Discharge records for new and expecting mothers found 3,714 women with at least one hospital visit for opioid misuse during the two-year period. Shockingly, for women who gave birth during the study period, 56 percent had an opioid-related encounter during her pregnancy, with 62 percent occurring in the third trimester and 25.6 percent on the day of birth.

The hospital survey also produced differing results. More than half of Missouri’s birthing hospitals — including those that account for 45 percent of all Missouri births and 50 percent of all NAS diagnoses — participated in the survey, which included both NAS severity and prevalence. At these hospitals, the reported perception of NAS severity correlated with conventional data. However, significant differences were found between hospital diagnosed and coded NAS and survey-reported prevalence — a range of 2.8 to 20 times higher than the rate identified through conventional diagnosis codes.

There are several important takeaways. It’s clear that the risk of NAS is higher than identified NAS in traditional surveillance. Experts suggest that more than half of newborns with a mother using opioids during pregnancy will suffer from NAS. If experts are right, maternal opioid use included in hospital discharge data would strongly suggest that NAS is undercounted. The gap is troubling. If the survey-reported data more accurately accounts for the actual prevalence, then not only is the NAS problem larger than anticipated, but it could be 400 percent larger.

Identifying a problem is usually easier than offering a solution. The policy brief takes on both.
NAS Policy Brief
Missouri’s Medicaid program pays for 83 percent of NAS deliveries, nearly twice the rate of non-NAS deliveries. Using existing prevalence data, Medicaid’s estimated additional hospital costs associated with NAS births were $10 million in 2016. These costs don’t include the additional downstream health care, social services and educational investments. Nor does this estimate account for the costs associated with the much larger NAS population evidenced through the alternative methodologies.

Since addressing NAS requires addressing maternal opioid or substance use disorder, Medicaid has a tremendous stake in reducing use among pregnant women. The only way to treat NAS is to treat it upstream.

Our policy recommendation includes providing evidence-based opioid use disorder treatment to low-income, uninsured women of childbearing age with substance use disorder prior to pregnancy. This would reduce the medical and societal costs associated with NAS by preventing NAS in the first place.

The policy brief projects that the cost of a federal Medicaid waiver that would provide access to substance use treatment to low-income women before they become pregnant would be offset by the avoided Medicaid costs to care for the NAS-affected babies these women would likely give birth to without the treatment. Avoided NAS births will result in avoided foster care placements. The policy brief estimates the 10-year cost to the state general revenue fund to provide upfront substance use treatment is $14.5 million less than the costs of NAS-related care that would otherwise be expected.

It would be easy to scapegoat and stigmatize mothers who misuse opioids and other substances during pregnancy. But doing so isn’t likely to reduce substance use disorder, improve their health or the health of their children — born or unborn — or save the direct and indirect costs associated with NAS.

In January 2017, our release was headlined, “Opioid Crisis’ Youngest Victims.” If the goal is to reduce harm to these victims — a population that may be much larger than we understood in 2017 — then our suggestions for a Medicaid-based policy is a solid starting point.

Let me know what you’re thinking.

Herb Kuhn, MHA President & CEO

Herb B. Kuhn
MHA President and CEO

In This Issue
CMS Releases Policy For Extreme And Uncontrollable Circumstances Policy For The CJR Model
MHA Participates In AHA's #HAVhope Efforts
Voluntary Recall Of Naloxone Hydrochloride Carpuject Injectors
CDC Releases Vital Signs Report On Suicide Rates
MHA Develops CHNA Implementation Plan Templates For Chronic Diseases
CMS To Publicly Release Hospital Sepsis Performance

Regulatory News
the latest actions of agencies monitoring health care

CMS Releases Policy For Extreme And Uncontrollable Circumstances Policy For The CJR Model

Staff Contact: Andrew Wheeler

The Centers for Medicare & Medicaid Services issued a final rule regarding extreme and uncontrollable circumstances for the comprehensive care for joint replacement payment model. This policy affects performance years two through five and applies to those hospitals located in areas hit by Hurricane Harvey, Hurricane Irma, Hurricane Nate and the California wildfires in 2017. This policy does not seem to impact hospitals in Missouri. MHA published an issue brief with additional details.

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Quality and Population Health

MHA Participates In AHA's #HAVhope Efforts

NAS Policy Brief Staff Contact: Jackie Gatz

Today is #HAVhope Friday, a national day of awareness that unites hospitals, health systems, nurses, doctors and other professionals from across the country, as well as the local and national organizations they work with, to combat violence.

Throughout the week, MHA convened members in a variety of settings to foster collaboration and develop safer care environments and resilient communities. On Wednesday and Thursday, MHA’s HIIN Quality Convening highlighted worker safety and patient safety, and on Friday, MHA, through the hospital preparedness program, conducted a statewide mobile communication exercise, ensuring that our established systems are in place to assist our communities in the event of an all-hazards incident.

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Voluntary Recall Of Naloxone Hydrochloride Carpuject Injectors

Staff Contacts: Leslie Porth or Shawn Billings

Hospira issued a voluntary nationwide recall for two lots of Naloxone Hydrochloride Injection, USP, in the Carpuject™ Syringe System due to the potential presence of particulate matter.

Please note that this recall only pertains to Carpuject injectors which are rarely, if ever, sold or distributed. This is a pen-like cartridge, which is fitted into an exoskeleton before use. This recall does NOT impact any of the intramuscular or nasal spray naloxone distributed by Missouri’s state-run grants or affiliated partners. Those requesting naloxone at pharmacies also are very unlikely to receive this product, but all pharmacies have been contacted about this recall.

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CDC Releases Vital Signs Report On Suicide Rates

Staff Contacts: Sarah Willson or Peter Rao

The Centers for Disease Control and Prevention issued a new Vital Signs report on the rising rate of suicide in the U.S. The report noted in 2016 that 45,000 Americans aged 10 or older died by suicide. The CDC reports this is nearly a 30 percent increase as a national average from 1999 to 2016. In Missouri, the rate increased by 36.4 percent. The CDC also developed a technical package to assist organizations and the communities in addressing the risk of suicide.

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MHA Develops CHNA Implementation Plan Templates For Chronic Diseases

Staff Contact: Stephen Njenga

MHA developed ready-to-use community health needs assessment implementation plan templates on diabetes and heart disease. The plans highlight key strategies, action plans, internal and external partners, process and outcome measures, and a timeline. They are based on the most current best practice strategies to address those key health issues using a multifaceted approach.

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CMS To Publicly Release Hospital Sepsis Performance

Staff Contacts: Sarah Willson or Leslie Porth

Sepsis is one of the most difficult conditions to detect and one of the most costly to treat. On Thursday, June 21, Wolters Kluwer Health is providing a free webinar on the reporting of Sepsis timelines and public reporting being implemented by the Centers for Medicare & Medicaid Services this summer. MHA does not endorse vendors; however, knowledge of affordable and timely education to possibly improve hospital performance is valuable.

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Did You Miss An Issue Of MHA Today?

June 4, 2018
CMS Releases Medicaid State Scorecards
June Is National Safety Month
This Week Is Community Health Improvement Week

June 5, 2018
Hospital-Acquired Conditions Save 8,000 Lives And $2.9 Billion
Medicare Solvency Date Shortened To 2026
This Week Is Community Health Improvement Week
CMS Updates IPFQR Program Resources

June 6, 2018
MHA Releases Policy Brief On Preventing Neonatal Abstinence Syndrome In Missouri
Issue Brief: Medicare Solvency Date Shortened To 2026
HIIN Members Convene In Columbia
ZIP Code-Level Data Assists Hospitals During Community Health Improvement Week

June 7, 2018
MHA Distributes Analysis Of Proposed Medicare Inpatient PPS For FFY 2019
MLN Connects Provider eNews Available
April MUR Available On HIDI Analytic Advantage®
Spotlight Hospitals Integrate CHNAs And Implementation Plans To Improve Community Health
CMS Announces OQR Education Session

Consider This ...

Today is #HAVhope Friday. Nationally, hospitals and health care providers are four times more likely to be victims of violence in the workplace compared to all other industries.

Source: Missouri Hospital Association