Health care ombudsman could cut through state's red tape, industry says

Grant Welker UMass Memorial Medical Center in Worcester.

Write a Comment

By State House News Service

Navigating different sets of regulations and state offices poses a challenge to those charged with patient care in Massachusetts, and an official "referee" could alleviate the problem by fashioning solutions in individual cases, health care industry officials say.

"We live in a regulatory environment that was built on a fee-for-service chassis, so the regulations that are in place make a lot of sense for that old world," Dr. Timothy Ferris, chairman and CEO of the Massachusetts General Physicians Organization, told lawmakers Wednesday. "As we move into this new world, we're faced with a sense of responsibilities where we directly, on a daily basis ... go up against regulations that actually don't make sense in the context of the ACO world."

The Baker administration is restructuring MassHealth, the state Medicaid program, towards an accountable care organization (ACO) model in hopes of better coordinating care and managing costs. The transition leaves medical providers "living in both worlds," said Ferris.

Addressing senators who are searching for cost control solutions, Ferris suggested "an ombudsman or an ombudsperson or some kind of role that allocates responsibility and some degree of freedom to make decisions that are in the best interest of patients, that cut through some of this red tape."

Senators want to generate legislation this fall and held the last of three forums, hearing from care providers, insurers, municipal representatives and other stakeholders. The Legislature in July rejected MassHealth reforms proposed by Gov. Charlie Baker, but said they'd come up with an alternative plan.

Two other participants Wednesday expressed support for developing some sort of ombudsman's office that could step in on matters involving different agencies.

Michael Caljouw, vice president of government affairs at Blue Cross Blue Shield of Massachusetts, said an ombudsman could be "particularly helpful" in addressing "boarding" patients in emergency departments -- when patients remain in the more costly emergency room because there is no other place for them.

"You want to make sure that the patient is taken care of in the right setting, but there's really not a requirement that another facility take a patient," he said.

Signature Healthcare Brockton Hospital President and CEO Kim Hollon said an ombudsman could help in situations where providers need to interact with multiple agencies whose services are not interconnected well.

He gave the example of a patient at the hospital, an elderly woman who is involved in the protective services program because she was abused by her family. She no longer needs hospital services, but staff do not want to discharge her to her home but must wait for another state agency to approve long-term services and supports for her, Hollon said.

"It's no fault of the system, it's how the system interacts with each other," he said,

The idea appeared to pique the interest of some of the senators in the working group, who asked questions about the potential role of an ombudsman.

"Don't we need here someone to be the integrator to cut through these services?" Majority Leader Harriette Chandler said, adding that it would be important for someone in such a role to have the power to act "swiftly."

Senate Ways and Means Chairwoman Karen Spilka said the person would act as a "referee" or a "facilitator," with "the authority to cut through all this bureaucratic stuff and say, 'This is what a person needs.'"