MMS Testimony Relative to MassHealth Section 1115 Demonstration Project Amendment and Extension Request

Comments on MassHealth Section 1115 Demonstration Project Amendment and Extension Request

The Massachusetts Medical Society appreciates the opportunity to provide comment on the MassHealth Section 1115 Demonstration Project Amendment and Extension Request. We applaud the transparent and inclusive process Assistant Secretary Tsai and his office has undertaken over the past many months to ensure ample stakeholder engagement.

The Medical Society has long been a proponent of the Medicaid program in Massachusetts as a vital source of health care coverage to many of our most vulnerable populations. We have watched closely as the growth trajectory of the program spending has increased markedly over the past few years, and appreciate that change must occur to ensure the sustainability of the system without significant reductions to eligibility or services covered.

The Medical Society supports many aspects of the waiver application: the expansion of substance use disorder treatment, the emphasis on behavioral health integration, and many initiatives through the DSRIP funding will serve the patients of the Commonwealth well while helping strengthen the health care delivery system. The Medical Society has concerns about other portions of the waiver: the reduction of PCC plan benefits and the 12-month lock-in could offset many of the improvements and jeopardize the care provided to this vulnerable population. Still other portions of the waiver—including new member attribution, the allocation process for the DSRIP funding, and data reporting requirements—have insufficient detail to be able to provide robust comments.

We are pleased to detail these areas of interest through the following comments:

  1. While the Medical Society supports the innovations and the promotion of integrated, accountable care as a valuable option in the MassHealth program, the MMS does not believe that they should come at the expense of the PCC plan.

    The Medical Society opposes the increase of co-payments and reduction of services in the PCC plan—including the elimination of chiropractic services, orthotics, eye glasses, and hearing aids—as a means by which to shift the source of care to ACOs. MassHealth should incentivize transition to ACOs by making the programs attractive to patients and physicians, not by stripping away benefits from the PCC plan. The latter approach penalizes patients who for many reasons may remain in a PCC plan. It further jeopardizes the continuity of the primary care physician-patient relationship: some physicians with small MassHealth panels may not ultimately choose to join an ACO. Their longstanding patients should not be put in a position of weighing the termination of their longstanding physician with a reduction in benefits and increase in out-of-pocket expense.
  2. The Medical Society applauds the expansion of the coverage of substance use disorder treatment through the Substance Use Disorder 1115 demonstration proposal.

    The Medical Society strongly supports the expansion of coverage to include the full continuum of substance use disorder treatment, from initial detoxification through long-term residential rehabilitation services. MMS also supports the expansion of combined detoxification and behavioral health stabilization in the same setting for adolescent patients. We hear often from our members of the particular difficulties that many of these dual diagnosed patients and their families face in finding access to and coverage for appropriate care. The MMS is also pleased to see the commitment of nearly 400 beds in FY17 and over 450 new beds in FY18.

    The Medical Society noted the commitment to continue the admirable policy of not requiring referrals for those seeking behavioral health care. We urge MassHealth to adopt a similar policy for substance use disorder treatment across all MassHealth plans. At a recent meeting of the Massachusetts Society of Addiction Medicine, several MassHealth physician participants referenced this issue as a barrier to care for patients who have finally decided to seek treatment.

    Additionally, the Medical Society supports the emphasis throughout the waiver on primary care-centered behavioral health integration and patient-centered care coordination for members with long-term support and services and social needs.
  3. A primary concern of the Medical Society remains the continuity of the primary care physician-patient relationship.

    The Medical Society appreciates the primary care physician based attribution model whereby patients will be placed in the MassHealth plan for which their PCP participates. The Medical Society looks forwards to additional detail about how new MassHealth enrollees without an existing primary care physician will be assigned to a plan.
  4. The Medical Society is concerned about the 12-month lock-in provision, especially in light of the complex plan design changes proposed in the waiver.

    The Medical Society has concern with the proposed change to implement 12-month lock-in periods for members. While we appreciate the difficulties that high rates of patient churn may pose, removing the flexibility could pose challenges to providing good medical care. Pediatricians have expressed concern, for example, about siblings who are unintentionally assigned to different primary care physicians. The Medical Society is thus opposed to the enrollment lock-in; though if the policy change is an inevitability we would strongly support expanding the specified reasons for disenrollment to include extenuating circumstances such as the sibling inconsistency cited above.

    The concerns about the enrollment change are exacerbated given the complexity of the health care delivery reforms that are proposed, including: multiple ACO models with varying involvement by managed care organizations, a retention yet reduction of the PCC plan, and the inability for dually eligible patients to partake in these ACOs. It is an understatement to say that it will be incredibly challenging for patients to fully understand the effects that these reforms would have on their primary care physician, on their plan design, and on their specialty medicine, behavioral health, and LTSS networks. These complex changes will undoubtedly cause many patients to find themselves with care design that they would like to change: this does not seem to be the most opportune time to limit flexibility of patients’ plan choice.
  5. MMS believes that a physician’s participation in one ACO should not disqualify the physician from participation in another ACO.

    The Medical Society appreciates that the waiver indicates that specialists will be able to participate in more than one ACO: we think this is vital to ensuring adequacy of networks for specialty care. Further, the Medical Society acknowledges the importance of ensuring that primary care physicians have a sense of loyalty to their patient’s ACO to ensure that care is coordinated and provided pursuant to the established network to the greatest degree possible. In light of this, the Medical Society offers the suggestion that some flexibility be provided for primary care physicians participating in multiple ACOs with the understanding that referrals will be made within the patients ACO to the degree possible. Some details would need further attention under such a proposal, such as clarifying to which ACO a patient would be assigned in their primary care physician belongs to multiple ACOs.
  6. MMS strongly supports many of the proposed uses of the DSRIP funding under the “ACO funding stream” but requests modification to ensure that funds are dispensed to hospitals and physician organizations of all sizes, with particular emphasis to small and medium-sized physician practices.

    The Medical Society welcomes the $1.8 billion requested to fund the many capital expenses required to properly transition to alternative payment models. It is often said that Massachusetts health care delivery systems are built on a fee-for-service chassis. Many expenses not imbedded in reimbursement will be required to help change the underlying structure needed to provide optimum population health and accountable care.

    Conceptually, the Medical Society strongly supports many of the proposed uses of the “ACO funding stream” DSRIP funds. Infrastructure funding to improve information technology, population health management capabilities, or to promote co-location and integration of behavioral health are all worthy uses of this money. However, in order for the DSRIP funding to truly inform care transformation to allow sufficient physician participation to provide network adequacy, the funding must reach the physician provider organizations who have the most acute capital needs. Small and medium sized physician organizations are often interested in joining ACOs but cannot due to their inability to comply with data reporting, or provide care coordination that adequately controls the costs of their patients. The Medical Society urges MassHealth to find specific venues or accountability structures to ensure DSRIP money flows to small and medium sized physician organizations. Participation of these physicians will be critical to the success the reform efforts.
  7. The Medical Society strongly supports several other DSRIP funding purposes under the Statewide Investment funding stream.

    Specifically, MMS was pleased to see additional commitments to student loan repayment programs for full-time physicians employed at community health centers, in exchange for two year service commitment. Additionally, the Primary Care Integration Model which would fund one-year projects related to accountable care implementation, as well as the Alternative Payment Methods Preparation fund which would help aid physicians looking to transition from fee-for-service are both welcome proposals, though many of the sentiments conveyed in #6 above would apply to ensure this money is provided to all physician provider types.

    Lastly, the Medical Society believes the investment in primary care residency training is a vital component of the long-term sustainability of the MassHealth program.
  8. The Medical Society supports the promotion of oral health, as well as the emphasis on addressing social determinants of health.

    MMS believes that oral health is an important component of the optimum health management of MassHealth patients. In 2009 the Commonwealth released a report, ‘The Status of Oral Disease in Massachusetts’ with a commitment to improving and promoting the oral health of our residents. Promoting good oral health improves overall health and nutrition, reduces costs, and can improve the quality of life of all individuals, especially underserved and vulnerable populations. MMS supports the emphasis placed on oral health, and encourages additional creative solutions through this waiver to improve the status of oral health and the integration of oral care in the Commonwealth.

    The Medical Society also supports the flexible spending serves as a means by which to improve the health of MassHealth enrollees and to address social determinants of health. The ability to use these funds for medically tailored meals, housing stabilization services, and employment supports provide great potential for evidence-based solutions to promote wellness. The Medical Society notes that additional flexibility on the ACO flexible spending criteria would be preferable: static “cost-effective” requirements may preclude well-established interventions such as housing stabilization and nutrition, which many not immediately conform to the current proposed requirements. The ability to use these funds for medically tailored meals, housing stabilization services, and employment supports would provide great potential for evidence-based health improvement interventions.
  9. MassHealth should work with the Centers for Medicare and Medicaid Services to ensure maximum alignment with impending changes to the Medicare program.

    The Medical Society has been actively engaged with CMS to provide comment about MACRA, a similarly ambitious and complex payment reform proposal for Medicare. Alignment in payment and delivery structure and in quality and reporting metrics will be essential to ensuring ample participation and successful retention of physicians to provide care under each program.
  10. Much of the long-term success of health care delivery and payment reforms proposed in the 1115 waiver will ultimately rest upon the details of the implementation of the accountable care organizations.

    MMS acknowledges that many of these details are outlined in the Health Policy Commission’s ACO certification, for which we provided extensive comment.

    The best designed MassHealth ACO will not be a sustainable model if the global budgets are not set at adequate rates that include special risk adjustment not just for physical health status but for mental health co-morbidities, long-term support and service needs, and social determinants of health. Funding for these global budgets need to be sustained over time, and must adjust for increases in wages, supplies, etc. Funding for other support services, such as the flexible funds that can be used for housing vouchers and medically appropriate foods, must be sustained as separate funding streams in the long-term, as well.

    Additionally, the quality and reporting standards should be consistent with other payers including Medicare, and physicians should be informed of the performance measurement expectations of an ACO, in order to best determine if they can meet or exceed expected quality and performance benchmarks that are outlined by the ACO.

The Medical Society greatly appreciates the opportunity to provide these comments, and welcomes further discussion of any of these considerations.





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