Children's Hospitals Today - Spring 2024 - 31

5 MINUTES WITH... / VITALS
Why did you as CEO feel it was important
to advocate for this legislation?
Blythedale, like most hospitals, experiences
denials in admissions and insurance
decisions that refuse to pay for
a continued medical stay even when
our pediatricians and sub-specialists
feel the admission or continued stay
is justified.
As a result, we've appealed adverse
Medicaid Managed Care (MMC) and
commercial insurance rulings over the
last four years, winning cases 90% of
the time. These external appeals take an
exorbitant amount of time away from
the bedside. I knew we had to write
legislation to address it.
Why should hospital executives be
involved in advocacy and how?
Hospital executives have a bully pulpit
and should use it. First and foremost,
we need to protect and advance the interests
of our hospitals so we can better
serve the children who so desperately
need our services, but we also need to
advocate for policies to help our patients
and their families.
In what specific ways did you help
advance the bill?
Getting this legislation signed into
law was a three-year effort. Through
persistence, compelling facts and data,
and solid political strategies-including
more than 70 meetings with legislators
and numerous state organizations-we
prevailed.
Sharing patient stories emblematic
of the challenges faced by medically
fragile children and their families
at meetings or during my testimonies
before the committees undoubtedly
helped them to understand that an
institution like Blythedale is a beacon
of hope to these families.
What are some key strategies for
influencing policy?
Staying bipartisan, sticking to compelling
facts and data, having clear objectives,
and constantly engaging the staffs
of legislators by educating them on the
issues impacting children's health.
A CLOSER LOOK
The new legislation
What did you learn through
this process?
I learned how important it was that
the bill was so narrowly and precisely
tailored toward a mere 0.7% of the
pediatric population. Legislators realized
the tremendous needs of this
tiny population, even in the face of
significant opposition from the main
lobbying organization for commercial
insurance and Medicaid Managed Care
companies.
What's next?
As we move forward, we have our eyes
on writing new legislation to address
the profound impact the nationwide
nursing shortage has had on home care
nursing. Medically fragile children
have highly specialized needs, and too
often community care providers are not
trained in the essential aspects of their
care. In addition, nurses are paid far
less to care for these patients at home
than they are in hospitals, and therefore
are not incentivized to provide this
vital care.
As we draft the legislation to address
this, we will work with a broad coalition
of hospitals, nursing homes, and child
and youth advocacy groups.
Blythedale Childrenʼs Hospital is a
specialty childrenʼs hospital dedicated to
the diagnosis, care, and rehabilitation
of children with complex medical and
rehabilitative needs.
See the top policy priorities for children's hospitals
at childrenshospitals.org/policy
" Chapter 170 of the Laws of New
York addresses unfair practices
in determining medical necessity
by ensuring accommodations and
special protections for medically
fragile children and the health
care facilities that care for them, "
Levine says. These are some of
the key provisions.
Defines " medically fragile
children " so commercial insurance
companies and Medicaid Managed
Care health plans can't exclude
children that should be covered.
Requires health plans to use
medical necessity criteria based
on pediatric guidelines, not those
for adults.
Requires the health plan's medical
reviewer to be board certified with
five years of experience in the same
specialty or subspecialty as the
child's treating physician, ensuring
decisions are made by the proper
pediatric experts.
Mandates a safe discharge,
including sufficient pediatric
subspecialty expertise and capacity
within the plan to handle the
volume. This includes adequately
trained home nursing care.
CHILDREN'S HOSPITALS TODAY Spring 2024
31
http://www.childrenshospitals.org/policy
Children's Hospitals Today - Spring 2024

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