In last year’s MHA Report of Accomplishments, I wrote that to succeed, “MHA and its member hospitals must be flexible and innovative.” I couldn’t know at the time that these skills would be so thoroughly put to the test in the coming months.
Although response to the COVID-19 pandemic significantly altered the environment in 2020, there were numerous, and in some cases landmark, achievements this year — including a major milestone in the successful adoption of Medicaid expansion through an initiative petition. This report is not a COVID-19 report. Rather, it is a full report on MHA’s major accomplishments. Nonetheless, given the weight of the COVID-19 pandemic on this year’s efforts, a separate narrative is included in this report to illuminate MHA’s efforts to help shape hospitals’ response and contribution to the state’s recovery.
Never has it been clearer that we rely on one another — hospitals and MHA, and hospitals together in efforts to safeguard the health and well-being of the communities we serve. The level of cooperation this year to address our monumental challenges has been unprecedented. In 2020, MHA often served at the nexus of these efforts — convening experts and opening channels; working with policy leaders to clear the path; and delivering the structures, data and operational tools to guide decisions.
The challenges and opportunities of 2020 will extend into 2021. We will continue the work to mitigate the impact of COVID-19 in Missouri, navigate the challenge of Medicaid expansion in a constrained budget, and work with state and federal partners to support hospitals through and beyond these immediate challenges.
As always, our strength is our ability to collaborate. Together, we are stronger than we are individually. And together, we will meet 2021 with the confidence that what we’ve learned and accomplished this year will cement our value among policy leaders and patients as pillars of strong, healthy communities.
Thank you for your partnership with MHA.
Herb B. Kuhn
President and CEO
Missouri Hospital Association
A printable PDF of MHA’s 2020 Report of Accomplishments is available.
Throughout 2019 and into 2020, MHA was engaged as a member of a coalition of stakeholders working to place Medicaid expansion on the Missouri ballot. In the spring, signatures were submitted and validated, and the measure was placed on the August ballot. Medicaid expansion was adopted by a seven-point margin due in no small part to the efforts of Missouri’s hospitals and MHA. MHA is actively engaging implementation partners to keep the measure moving forward according to the constitutional timeline.
While this year’s General Assembly was truncated due to COVID-19, lawmakers took action to support hospital finance. This includes enactment of legislation authorizing additional FRA-supported Medicaid Disproportionate Share Hospital payments in fiscal year 2021. Lawmakers authorized $60 million in additional funding for unbudgeted Medicaid fee-for-service hospital payments in the current state fiscal year. At the same time, new payment capacity was realized in 2020 through MHA’s DSH audit litigation against the Centers for Medicare & Medicaid Services. Based on new legislative authorization, staff are working with the MO HealthNet Division to distribute in 2021 $160 million in unspent DSH allotments for previous fiscal years. Finally, lawmakers appropriated funding to support the expected increase in payments to hospitals for Medicaid services in FY 2021, which began July 1, despite the state’s dire budget outlook.
Working with the Parson administration, MHA and hospital advocates convinced MHD to change its plans to use the Medicaid cost report for rural health clinic settlements. MHD initially planned a retroactive application, which would incur significant and unexpected losses for many hospitals with RHCs.
MHA also worked to renegotiate a memorandum of understanding with the three Medicaid managed care plans to ensure that hospitals receive “full Medicaid pricing” payments for hospital services flowing through the plans. The change will take effect during the current fiscal year.
Several important liability protection measures were adopted. The new laws create a more rigorous threshold for awarding punitive damages in lawsuits against health care providers and others, and bar lawsuits against health care providers based on the Missouri Merchandising Practices Act if the claim could be brought as a medical malpractice lawsuit.
Missouri’s health care workforce and finance challenges are exacerbated by insurance companies’ delay in credentialing providers. Legislation enacted in 2020 sets deadlines for insurers to request further information and act on a practitioner’s credentialing application for the insurer’s provider network. The law mandates that, if the practitioner credentialing application is approved, the insurer will make payments for the practitioner’s covered services on behalf of the contracted entity from the date of application to its approval.
Legislative success isn’t confined to the number of laws that are adopted. Often, efforts to blunt legislation that would lead to harm rank as important as getting legislation accomplished. While there are too many items to list, efforts to delay implementation of an outpatient fee schedule and success in blocking the elimination of the out-of-state payment system stand as examples of effective advocacy to reduce harm to hospitals.
Regulatory advocacy is essential to remove unnecessary burdens and improve hospitals’ operational environment. In 2020, MHA made significant progress in working with state and federal agencies to support better and more efficient care.
26 Acute Care Hospital Licensure Checklists
APRN and PA Inpatient Restraint Clarification
CMS Sepsis 2 Definition Clarification
DSS Children’s Division Medication-Informed Consent Policy Change
Strengthening Time Critical Diagnosis Systems
Foster Care Behavioral Health Carve-in For Medicaid Managed Care
Policy Engagement On Victims Of Sexual Violence
MHA-Missouri Attorney General Guidebook On Human Trafficking
In addition to foundational harm reduction, many of MHA’s initiatives focus on vulnerable populations. Missouri ranks 44th in the nation for maternal mortality, with a death rate of 40.7 mothers per 100,000 live births. MHA is spearheading several efforts — in concert with the state and other partners — to reduce the toll of maternal mortality. Through the Alliance for Innovation on Maternal Health collaborative, MHA is assisting hospitals with a data-driven quality improvement program to reduce maternal mortality and severe maternal morbidity. This year, MHA completed more than 40 coaching calls and 11 virtual shared learning meetings, and facilitated peer-to-peer educational programming.
High blood pressure can lead to preeclampsia and eclampsia — two significant causes of maternal mortality and harm. MHA received a $150,000 grant from the Missouri Foundation for Health to provide blood pressure cuff kits for at-risk expectant mothers. Cuff kits provide education and allow at-risk patients to monitor their blood pressure at home, and address issues through telemonitoring and telemedicine.
Drug use, including opioids, is a contributor to the maternal health crisis. MHA is a partner in the Missouri Neonatal Abstinence Syndrome Collaborative to improve maternal health and care throughout pregnancy and after delivery.
Missouri’s opioid and substance use crisis is a major health challenge. MHA partners with the Missouri Department of Mental Health, providers and communities to build better access to care, appropriate treatments and a framework for recovery through the Engaging Patients In Care Coordination, or EPICC, program. MHA has led partnerships that now expand throughout the state, extending substance use treatment to a much broader population. Missouri adopted a medication-first model, which incentivizes rapid and sustained access to U.S. Food and Drug Administration-approved medicines to treat opioid use disorder.
Through EPICC, substance use disorder is destigmatized, overdose care mitigation has been expanded, and counseling and peer-coaching has become more available. The EPICC program design utilizes peer recovery coaches in the ED. Due to the COVID-19 pandemic, this program was rapidly redesigned to support virtual counseling sessions and increased referrals directly from emergency management services. Early data suggest spikes in opioid- and other drug-related mortality during the COVID-19 pandemic, rising by roughly 18%. This is attributed particularly to illicitly manufactured fentanyl and fentanyl analogs.
Missouri was facing significant short- and long-term workforce challenges as it entered the COVID-19 pandemic. These difficulties likely will worsen in the months and years ahead. MHA continues to monitor workforce issues through the network of hospital human resource professionals. At the same time, staff are engaging HR, clinical and academic leaders to keep incumbent workers in the system, and new and future workers joining in and progressing through the system.
MHA continues to manage hospital emergency preparedness readiness and response through a grant from the Missouri Department of Health and Senior Services. This close connection to DHSS has been essential during the COVID-19 pandemic. The achievements noted this year are further described in the COVID-19 section.
In 2020, CMS approved the Admission Discharge Transfer program for Medicaid, as proposed and budgeted by the state. Through a partnership with Collective Medical, HIDI is expanding ADT capture and alerting capabilities to assist hospitals in meeting the new Medicare Conditions of Participation, while enhancing the value of near real-time, risk-based alerts. The system will apply analytics to improve collaboration among providers and reduce ED utilization and inpatient readmissions — a hospital community priority. Moreover, the system is being expanded from its existing scope to identify COVID-19-related data.
Analysis has driven successful negotiation for and against proposals at the state and national level. Informed data identified MHD’s underestimation of the negative hospital impact of the outpatient fee schedule, helped explain the influence of Medicaid expansion and assisted budget-makers in understanding how to maximize DSH payments.
Using the University of Missouri’s Show-Me Extension for Community Health Outcomes, or ECHO system, MHA experts are extending their reach. This has been essential during the COVID-19 pandemic when traditional delivery of knowledge and best practices have been eliminated or reduced. MHA experts have participated in ECHOs related to maternal health, COVID-19 and other high-priority topics.
COVID-19 has caused numerous changes in our delivery of knowledge. The MHA Health Institute canceled all 2020 in-person events due to COVID-19. Since March, MHI has pivoted 100% to virtual events, including MHA’s 98th Annual Convention.
This year’s biennial Membership Survey recorded an all-time high in members reporting MHA’s overall performance as excellent. For the first time, 100% of respondents reported MHA as an Excellent or Good Value. This year’s survey allowed members to identify strategic priorities for MHA, including Medicaid expansion, reform and implementation; telemedicine; and redesigning the rural health care delivery systems in the state.
The connection between MHA and the hospital community is stronger than ever before as together we respond to the COVID-19 pandemic and tackle implementing Medicaid expansion. The daily interaction with our members allows us to understand the emerging issues and shape the future of health care in Missouri. In 2020, MHA launched a new Chief Operating Officer Network to increase engagement and networking by member COOs. This network is one of several that provides connections to help hospital leaders identify common challenges and common solutions.
Already difficult issues with the health care workforce became even more pronounced in 2020. MHA continues to bring hospitals together with colleges, the public workforce system and other stakeholders to help identify regional health care worker needs and develop strategies to address them. In addition, 2020 was the final year for the Health Profession Opportunity Grant, a five-year grant funded by the U.S. Department of Health and Human Services and administered by the Missouri Department of Social Services Family Support Division. MHA served as a liaison between the Central, St. Louis and Kansas City region Workforce Investment Boards to coordinate efforts among hospitals to help low-income individuals receive training for in-demand entry-level jobs in health care. For the grant year ending Sept. 30, 2020, there were 1,409 participants that completed health care occupational training in the St. Louis, Kansas City and Central regions, and 1,071 participants obtained employment in a health care occupation.
Strategic investments in the future of the organization continue with improved data and analytics, support for quality and safety improvement, and a strong local and statewide advocacy program for hospitals — foundational to the success of all hospitals. MHA is committed to ensuring hospitals have both the tools they need to succeed, and the policy environment to focus on the efforts that improve not just health care, but health.
Our values are consistent — MHA’s goal is to help hospitals serve their communities. To achieve this goal, we’re committed to going above and beyond so that hospitals can succeed today, and continue to lead in improving health, tomorrow.
Understanding And Shaping The Environment
Beginning in and since January, MHA has — through a variety of approaches — provided data for decision-making and resources to help hospital and statewide leaders understand the evolving COVID-19 environment. MHA and HIDI have contributed to the real-time awareness of the disease in Missouri. At the same time, MHA continues to work with state and federal officials to direct resources and assistance to support hospitals and the health care system.
MHA is the state’s contractor and partner in hospital preparedness. As a result, MHA was well-positioned to work with both hospitals and the state in response and recovery efforts. Operationally, MHA participates in the state’s fusion cell to maintain real-time situational awareness and advocate for hospitals during all aspects of the state’s pandemic response. This relationship allows daily interaction with agency teams throughout the Parson administration.
Throughout winter and spring, hospitals were required to quickly pivot away from standard operations to address the COVID-19 pandemic. MHA was at the center of communitywide discussions on how and when changes would occur, and how to create a regulatory and operational framework for the transition and during the life of the crisis. The challenges were multifaceted, requiring engagement among hospitals, multiple levels of government and with the public. Moreover, the crisis extended to nearly all parts of hospital organizations, including finance, infection control, regulatory compliance, community relations and human resources.
Financial Support For Hospitals
MHA has and continues to advocate for financial support for hospitals. Reduced utilization — in part because of reduced medically necessary elective procedures and in part due to the public response to the crisis — placed many hospitals in immediate financial jeopardy. MHA worked with Missouri’s Congressional Delegation to craft financial relief for hospitals. Through congressional action, Missouri’s hospitals received direct relief payments of approximately $1.2 billion, between $52 million and $116 million through the Paycheck Protection Program, and $1.9 billion in Medicare accelerated payments. The latter was a direct outgrowth of an MHA membership conference call with Missouri’s U.S. Senators.
Through negotiations with the state, MHA secured the release of $42 million in Medicaid funds due to hospitals to provide additional state financial assistance.
In April, a five-year funding opportunity serving as a prime contractor was offered to MHA by the HHS Office of the Assistant Secretary for Preparedness and Response to directly support Missouri hospitals’ response to COVID-19 through several allowable activities, including training, plan development, acquisition of personal protective equipment and expanding surge capacity.
MHA submitted an initial application for $1,097,697 in allocated funding with the directive that a minimum of 90% of the award would be disseminated to the 109 participating hospitals within 30 days of award. A supplement of $2,727,042 later was awarded to MHA. With the second round of funding, MHA is developing a COVID-19 hospital collaborative designed to address several critical issues identified as lessons learned throughout early response. Participating hospitals will receive milestone funding opportunities upon achievement of benchmarks identified within each focus area, as prescribed by ASPR.
Although utilization recovered faster than anticipated when hospitals reopened for elective procedures, full recovery will take much longer. MHA supported hospital reopening with a campaign, including billboards in several parts of the state, reminding Missourians that hospitals were open and ready to provide care.
The pandemic continues to move throughout the state, affecting rural hospitals much more acutely in late 2020. MHA continues to advocate for hospital relief in federal COVID-19 legislation.
To support hospitals during the crisis, MHA worked with state and federal officials to identify rules that could create care and organizational roadblocks, and craft waivers to address necessary changes in regulatory standards. To help hospitals understand the new environment, MHA developed an online state and federal waiver tracking tool.
Throughout the crisis, MHA developed guidance and best practices specific to the new challenges. In addition to delivering these resources to hospital leaders through newsletters and updates, MHA hosted webinars to explain and expand on the topics.
Data For Decision-Making
MHA and HIDI continue to expand statewide COVID-19 data dashboards to deliver daily and weekly updates on the status of the pandemic in Missouri. Through various stages of evolution, these tools have expanded to include leading indicators of the disease’s progression in Missouri and contemporaneous data, including the status of influenza-like illness for flu season. MHA works with state data experts and partners with Washington University in St. Louis to continually develop the data and enhance the presentation for decision-makers and the public.
A dedicated portion of MHA’s website includes all COVID-19 information, sorted by subject matter, to provide access to historical and the most current information on the disease. COVID-19 update emails — delivered daily through the summer, and twice weekly into fall — have provided regular situational awareness throughout the pandemic.
Providing Federal And Statewide Leadership
The COVID-19 pandemic has reinforced the connectedness of the state’s hospitals. MHA provided a platform for hospital advocacy and statewide, regional and local situational awareness. Throughout the pandemic, to help hospital leaders understand the state’s status and priorities, MHA facilitated calls with Gov. Mike Parson and leaders from the administration. It also convened regular calls with Missouri’s congressional delegation and staff.
MHA staff work directly with the state’s response team, regional response organizations, and hospitals and health systems. This allows MHA’s team to understand issues as they develop and address them quickly.