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Massachusetts Health Policy Commission
October 2018
This month’s newsletter features highlights from the HPC’s 6th Annual Health Care Cost Trends Hearing, as well as key lessons learned and patient stories related to timely access to behavioral health care, a key topic of discussion during the hearing.

Let us know if there are particular care delivery transformation topics or work in the Commonwealth that you’d like to see the HPC showcase in this newsletter. We'd love to hear from you! Email us at HPC-Caredeliverytransformation@mass.gov.  

Team HPC
The 2018 Health Care Cost Trends Hearing
On October 16 th and 17 th , representatives from health care provider organizations, community-based organizations, payers, employers, advocacy groups, government agencies, pharmaceutical companies, academia, the legislature, and the interested public attended the 2018 cost trends hearing hosted by the HPC, along with the Center for Health Information and Analysis (CHIA) and the Office of the Attorney General (AGO). The cost trends hearing is a public event at which policymakers and researchers convene to discuss challenges and opportunities in improving health care and reducing costs in the Commonwealth, to advance the Commonwealth's goal of ensuring access to high-quality, affordable health care for all. 
The two-day hearing featured a robust agenda , including a keynote discussion of U.S. health care spending through an international lens by Dr. Ashish Jha of the Harvard Global Health Institute, and a spotlight on state solutions to health care spending by Trish Riley, Executive Director of the National Academy of State Health Policy (NASHP). Governor Charlie Baker and Speaker of the House Robert DeLeo contextualized the event by highlighting key areas of focus for health care in the Commonwealth while Attorney General Maura Healey reported on her office’s findings in a study on payment methodology variance among different providers and payers. Slides for the presentations can be found on our website .

In addition to these presentations, the hearing featured four witness panels on the following topics:
  • Meeting the Health Care Cost Growth Benchmark: Top Trends in Care Delivery and Payment Reform
  • Innovations to Enhance Timely Access to Primary and Behavioral Health Care
  • Strategies to Address Pharmaceutical Spending Growth
  • Impact of Nurse Staffing Ratios on Cost, Quality, and Access
Prior to the hearing, the HPC issued requests for written pre-filed testimony (PFT) from payers and provider organizations to inform various research and policy efforts, including the HPC’s annual Cost Trends Report. Fifty organizations responded to the request for pre-filed testimony this year, which covered topics such as strategies to address health care spending, price transparency, and timely access to care. The top areas of concern cited for meeting the health care cost growth benchmark included the potential implementation of mandated nurse staffing ratios, rising pharmaceutical costs, provider price variation, and a lack of resources for and access to behavioral health. To address these areas of concern, payers suggested policy changes related to reducing pharmaceutical spending and price transparency as top strategic priorities, while health care providers were interested in enhanced collaboration and coordination across care settings, including increased integration of behavioral health care into primary care.

The HPC would like to thank all of the PFT respondents as well as the speakers, moderators, and attendees of the event for a thought-provoking and engaging conversation. Please continue to look to our newsletter and website for updates on our annual Cost Trends Report, and other upcoming publications.
Tele-Behavioral Health Integration into Primary Care
Telemedicine has been shown to be a cost-effective means of expanding timely access to behavioral health (BH) care, augmenting provider BH capabilities, and more consistently delivering patient-centered care 1 . As was highlighted and discussed during the cost trends hearing, while access to BH services remains a critical gap in the Commonwealth’s care delivery system, telemedicine remains underutilized in Massachusetts.

The HPC has made several investments to date in telemedicine services for BH (teleBH) in order to deliver better, more timely BH care across the Commonwealth. The awardees of these investments have surfaced several lessons from implementing those models in the areas of technology, workforce, workflow, and data and measurement. Many of these ideas were discussed at the HPC’s April 2018 roundtable discussion with teleBH awardees, moderated by staff from Health Management Associates.
Technology: The importance of defining business needs before choosing the technology

“Some clinics and centers buy into contracts before they have a clinical model set up, and then they find out later that the vendor of the platform can’t do what they want to do, so contracting with your vendor should be one of the last things that you do.” — Health Management Associates
Workforce: The potential for new provider perspectives and roles on the team

“Importantly, [teleBH services] changed the provider experience—the pediatricians in the office were so positive that when the grant went away, people were unanimously saying we need to keep [social worker trained in behavioral health] sustainable, regardless of fee-for-service payments and we will take a cut in our salaries if necessary to keep her going.” – Yogman Pediatrics
Workflow: Opportunities to streamline the intake process to facilitate access

“We changed [our intake process] so that the primary care provider has the ability to identify the patient, [and] offer them the opportunity for telehealth—much easier to get the consent right at that moment.” – Pediatric Physicians' Organization at Children's ( PPOC)
Data and Measurement: Opportunities to leverage new data
“[W]e have school data, which is actually very telling because we can really make some judgments about whether this is effective—it shows up in academic records and attendance records, in ways in which the kids are functioning better in a school setting, but school data is probably even harder to get than medical data.” — Heywood Hospital

These and other takeaways from the telemedicine pilot investments will be highlighted in an upcoming HPC publication, intended to inform any interested provider—regardless of licensure, practice type, or location— that may be contemplating incorporating teleBH care into their practices.

1.   Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper http://annals.org/article.aspx?articleid=2434625
Telemedicine and Behavioral Health: School-based Care Through Heywood Hospital
Funded through the HPC's Health Care Innovation Investment (HCII) Program, Heywood Hospital’s telemedicine pilot delivers BH services to students at two north-central Massachusetts schools. The referral model brings together the schools’ guidance counselors, school-based care coordinators, and other school staff, allowing students with appropriate needs to benefit from the initiative. Heywood staff shared two stories of students who received services from the teleBH program.
One student had chronic suicidal ideation, as well as a number of other symptoms of mental illness, due to a severely traumatized nervous system and attachment disruption. The student was connected with the initiative’s licensed mental health counselor and spoke with her via a secure telehealth platform located in a designated space in the school. The student was able to make a strong therapeutic connection during counseling and continued to reach out to staff, including the school-based care coordinator, who acted as a liaison between the initiative and the school’s traditional student support system. After engaging in the program, the student showed increased health-seeking behavior and chose to continue working with a counselor after involvement with the program ended. 
A second student was initially hesitant to accept not only BH services, but any adult intervention or connection. The student showed signs of adverse childhood experiences, and spent the first several sessions with the clinician attempting to leave the program. One benefit of the telehealth platform is the ability for students to communicate with the clinician via real time text-based chatting, rather than oral communication. Over time, utilizing this option of texting the counselor rather than physically sitting in a session, the student engaged in counseling regularly and was able to create a bond with the therapist. Through this connection, the student was able to discuss values and interests. The Heywood team found that, as is common with adolescents with attachment trauma, a significant component of the clinical work is establishing enough trust to have these kinds of conversations.

For both students, there was a clear need for counseling to help them with chronic, challenging mental health issues. Integration of the program into the school removed access as a barrier, and the students were able to get help without disrupting their or their families’ schedules. Additionally, the engagement options with the telehealth platform increased accessibility for a wider array of students, depending on their needs and preferences.
SHIFT-Care Evaluator Procurement 
The HPC has released a request for response (RFR) for a mixed methods evaluation of a cohort of SHIFT-Care initiatives. The evaluation will include nine sites implementing a program to increase real-time access to BH care by providing emergency department (ED)-based initiation of pharmacological treatment for opioid use disorder (OUD) and facilitated connections to ongoing treatment. The vendor will study the impact of the care model on key outcomes including initiation and engagement in OUD treatment, ED utilization, and patient experience. The RFR and preliminary evaluation design can be found here:  RFR for Evaluation Services. Responses are due by 3:00 PM on November 9, 2018. 
Community Emergency Medical Services and Mobile Integrated Health   
The HPC is excited to share that the Massachusetts Department of Public Health  (DPH) is currently accepting applications for Community Emergency Medical Services and Mobile Integrated Health (MIH) service providers. These new programs utilize mobile resources to deliver care and services to patients in the community in coordination with health care systems. DPH launched three programs to address gaps in illness prevention and health care service delivery:

  • Community EMS is a collaborative system to address illness or injury prevention through high value public health services in the community.
  • MIH is a system of pre- and post-hospital services that utilizes mobile resources, including EMS Personnel, community paramedics, and other providers to deliver a coordinated continuum of care that supports patients’ needs in the community.
  • MIH with ED Avoidance is an additional component of an approved MIH Program that allows for management of 9-1-1 patients, as appropriate and in accordance with the DPH ED Avoidance Protocol, in alternative settings including outpatient clinics, psychiatric facilities, and the patient’s home.
The HPC has made investments in models that use MIH through the Targeted Cost Challenge Investments (TCCI) and the upcoming SHIFT-Care Challenge investments. One of these models is Commonwealth Care Alliance’s (CCA) partnership with MIH provider EasCare Ambulance, recently highlighted in a Boston Globe article titled “A new role for paramedics: treating patients at home.” Through its TCCI award, CCA continues their innovative work to provide appropriate and effective care to OneCare and Senior Care Options patients with complex medical and BH needs. MIH is one of several facets of CCA’s TCCI program focused on reducing hospitalization and ED visits. The care model allows paramedics to visit and treat patients in their home without transporting them to a hospital; triage at CCA can dispatch calls received outside of office hours to the MIH providers, and primary care and BH providers can also take advantage of the after-hours care to schedule visits for specific patients to help them manage their chronic conditions. CCA estimates that their MIH initiative has saved close to $6 million since the launch of their pilot in 2014. In light of the opportunities available through the new DPH regulations, CCA hopes to deepen and expand their utilization of MIH in the future.

More information about these programs and how to apply can be found here .
Behavioral Health Network Awarded a SAMHSA Grant 
The HPC is pleased to congratulate Behavioral Health Network (BHN) on being awarded $4M through a two-year Substance Abuse and Mental Health Services Administration ( SAMHSA) Certified Community Behavioral Health Clinics (CCBHCs) Expansion grant. The purpose of the CCBHC Expansion Program is to increase access to and improve the quality of community BH services through the expansion of CCBHCs.

The HPC has partnered with BHN through the HCII and SHIFT-Care programs to expand innovative BH service models in Central and Western Massachusetts. The only Massachusetts project distinguished with this award, BHN’s CCBHC Expansion project aims to increase access to high quality, integrated BH and recovery supports for patients of their primary care community partners in order to reduce total costs of care through reductions in BH symptoms and unnecessary utilization, and to ultimately develop a value-based payment model to sustain CCBHC services and innovation.
Massachusetts Health and Hospital Association Social Determinants Event 
On Friday October 19th, the Massachusetts Health and Hospital Association (MHA) hosted “The Role of Social Determinants and Cultural Awareness in Caring for Populations and Patients,” a program focused on how caregivers and communities are coming together to provide innovative and targeted care to help patients get and stay healthier. HPC Executive Director David Seltz shared the HPC’s policy and programmatic work related to supporting providers to address health-related social needs. He reviewed the HPC’s analysis of pre-filed testimony for the 2018 cost trends hearing, which reflected many providers’ interests in and the barriers to integrating medical services with those provided by community-based social service organizations. He presented an overview of the HPC’s relevant investments in pilots to address patients’ health-related social needs, and also highlighted efforts through the ACO Certification program to support ACOs and communities in addressing the health-related social needs of their patient populations.
Economic Mobility Pathways (EMPath)
Boston, MA
November 1-2, 2018

Boston University Questrom School of Business
Boston, MA
November 2, 2018

Brigham and Women’s Hospital (in collaboration with HPC, MassChallenge HealthTech, and MeHI)
Boston, MA
November 14, 2018

Massachusetts Health and Hospital Association
Burlington, MA
November 9, 2018

Massachusetts Health Data Consortium
November 15, 2018

Health Policy Commission
November 28, 2018

Massachusetts League of Community Health Centers
Westborough, MA
November 28, 2018

Massachusetts Health Data Consortium
Waltham, MA
November 28, 2018

Office of Attorney General Maura Healey

Center for Health Information and Analysis (CHIA)

Blue Cross Blue Shield of MA Foundation

Center for Health Care Strategies

Bureau of Substance Abuse Services
Massachusetts Department of Public Health
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109