The Massachusetts Medical Society, on behalf of over 25,000 physicians, residents, and medical students across all clinical disciplines, organizations, and practice settings, appreciates the opportunity to provide comment to the Executive Office of Health
and Human Services on the Section 1115 Demonstration Extension Request. The Medical Society is committed to advocating on behalf of patients for a better health care system, and on behalf of physicians, to help them to provide the best care possible.
We see the MassHealth program, and its 1115 Waiver, as critical means toward accomplishing those ends, and as such, we applaud the transparent and inclusive process undertaken over the past many months to ensure ample stakeholder engagement.
The Medical Society has long been a proponent of utilizing the Medicaid program in Massachusetts as a tool for innovation and for improving coverage and delivery of services and social supports for our most vulnerable populations. While we wholeheartedly
support the nationwide, federal approach to providing such coverage, we appreciate the flexibility afforded to the states that allows for thoughtful innovation in health care. This advancement is necessary to ensure the sustainability of the system
while also equitably expanding eligibility and covered services.
Overall, the Medical Society strongly supports the goals of this waiver application that seek to continue progress in improving health outcomes and reducing health disparities. We would like to present comments on the implementation of some of these objectives.
We are pleased to detail these areas of interest through the comments below.
Accountable Care Organizations
The Medical Society is supportive of the continuation of the Accountable Care Organization (ACO) program and the proposed changes aimed at improving the program based on lessons learned. We applaud the focus on improving health equity and reducing disparities,
which is apparent through all program design changes. We appreciate that expanding incentive payments to Model B ACOs based on combined performance on quality and health equity indicators will not only improve quality accountability but also improve
equitable health outcomes. While we appreciate the considerations and practical experience that informed MassHealth’s decision to discontinue the Model C ACO, we urge to you continue to consider alternative structure offerings that can provide a meaningful
entryway to risk-based contracting for physician practices with smaller membership numbers. Such an offering could include, for example, no downside risk and upside only risk based on performance on quality and equity measures. This will help encourage
more providers to participate in the MassHealth ACO program and accelerate adoption of value-based care.
We value the state’s commitment to investing in primary care and behavioral health care and particularly its commitment to addressing the unique needs of children, youth, and families. Looking beyond the primary MassHealth member to the family unit as
a whole is a holistic approach that will make progress toward improving the population health of our most vulnerable communities.
Care Coordination
MMS also supports efforts to streamline and improve care coordination, including the creation of a new Targeted Case Management benefit to support the highest risk, most medically complex children. We are encouraged by the signs of success of the Community
Partners program and believe that having ACOs contract directly with Behavioral Health Community Partners (BH-CPs) and Long-Term Services & Supports Community Partners (LTSS-CPs) will promote improved integration and access to these critical services.
Moreover, while there is an abundance of care coordination resources for patients, we often hear from our physician members about the confusion generated from multiple points of contact, which ultimately undermines care coordination efforts. Efforts
to streamline and create a three-tiered framework for care coordination with standardized approaches will help address these concerns. We also support improving network adequacy by increasing the minimum number of contracted BH-CPs and LTSS-CPs to
deliver MassHealth-defined supports. The Medical Society would like to understand additional detail behind the actuarial calculations that will be used to develop administrative payments to ACOs to directly pay BH-CPs and LTSS-CPs, as opposed to those
CPs receiving direct payment from the state. Moreover, we would appreciate additional clarity relative to the responsibilities of the ACO versus the BH-CPs/LTSS-CPs to identify members and determine what level of care coordination is warranted. Lastly,
we would like to better understand how specialized care coordination for high- and rising-risk members meeting specific medical necessity criteria will interplay with the standard care coordination programming.
Primary Care Payment Reform
The Medical Society applauds MassHealth for its attention to primary care throughout this waiver proposal. MMS has long supported greater investment in and improvements to primary care. We supported primary care reforms and investments in the last waiver—including
support of care coordination and IT infrastructure for population health programs—that likely helped lead to the reported increases in primary care utilization within the MassHealth ACOs over the past several years. We see the role of primary care
within medicine as increasingly critical, especially for patients with complex medical and social needs. MMS has long envisioned the potential of primary care through initiatives such as behavioral health integration, greater care coordination, and
greater abilities to tend to the social needs of patients. In order for the visions of primary care to be realized, however, reimbursement rates and payments systems must be aligned with these ideals.
MMS supports the adoption of alternative health care delivery systems such as ACOs and the global payment structures that accompany them. MMS supports movement toward the capitated payment structures that ACOs promote, while also appreciating the need
to retain other payment models such as fee-for-service to allow for different physician practice types to select the payment model that best serves their practice and patients. We feel this is well reflected in the growing MassHealth ACO program alongside
the continued existence of the PCC plan. We continue to underscore, as we did in waiver comments five years ago, the value of physician participation in the governance of ACOs and in public policy discussions about the future structuring of these
organizations.
MMS appreciates that a system that pays ACOs on global, capitated bases, but that permits the ACOs to pay for underlying primary care on a fee-for-service basis, will be unlikely to bear the fruits of the intention and potential of ACOs to promote the
highest value care. We thus support MassHealth conceptually as it endeavors to establish a sub-capitation payment system for primary care. The flexibility and predictability of such prospective payments, if structured properly, could be a meaningful
step in allowing primary care to implement many of its preferred reforms. Proper risk adjustment, inclusive of social risk factors, will continue to be critical to assuring success of any program. We appreciate the elimination of an administratively
burdensome required back-end reconciliation against utilization, which has often been present in commercial sub-capitation pilot programs.
There are many features of this proposal that appear promising. MMS supports MassHealth in proposing a tiered payment system that proportionally increases the sub-capitation rate based upon the practice’s capabilities on key areas such as behavioral health
integration, care coordination, unique needs of children, youth, and families, and expanded access. We believe that higher payments based upon this tiering construct will incentivize and reward investments in more expansive services. We wish to underscore,
however, the reality that many of these capabilities require capital, upfront investment by practices. We therefore encourage continued funding and technical assistance to practices who wish to increase these capabilities with a desire to better serve
their patients and to increase the tiering and resulting payment.
Beyond many of these conceptual discussions is the reality that the merits of a sub-capitated payment proposal are largely grounded in the actual level of funding. The Medical Society urges the release of additional detail to better assess the adequacy
of the proposed payments. Primary care has not benefited from many of the supplemental funding sources available to hospitals who serve similar populations. We continue to call for increases in reimbursement to create sustainable models of integrated,
high-quality physician practice that serve MassHealth members. We further urge accompanying resources to allow for transformation for physician practices toward higher tiers of care through expansion of services and capabilities for patient care.
Behavioral Health Reform
The Medical Society has prioritized advocacy in furtherance of an improved behavioral health system. We have worked extensively with stakeholders in this space to improve payment, workforce, and ultimately, access to high quality behavioral health for
all patients in the Commonwealth. We believe the Massachusetts Roadmap for Behavioral Health is an important step in the right direction. We support accompanying financial investments in behavioral health infrastructure, and we support the
better care coordination proposed for patients with complex behavioral health care needs.
On the issue of workforce, MMS supports continuation of loan forgiveness for primary care and behavioral health professionals, including psychiatrists, who pledge to work in settings with high MassHealth membership settings.
Children, Youth, and Families
The MMS strongly supports the specific attention given in the waiver to improvements of the care of children, youth, and families. Improvements in pediatric behavioral health care (as embedded in the Roadmap), in family-centered care coordination
of pediatric patients, and in health equity work to improve maternal and child health, are all enthusiastically welcomed by MMS and consistent with similar advocacy to drive analogous improvements in the commercial market.
Incentivized Data Collection
The Medical Society highly commends the commitment to advancing health equity through a focus on initiatives that address health-related social needs and specific disparities. Importantly, this proposal includes a critical first step toward improving
health inequities: incentivizing the collection of accurate social risk factor data on an aligned measure set to better understand why and how health disparities originate. The insights gleaned from the collection of such data will help to guide development
of effective interventions and performance measure approaches that seek to identify and eliminate inequitable health disparities. The proposed incentive payments will allow physicians serving disproportionately socially-at-risk populations to focus
on health equity performance. The Medical Society looks forward to staying engaged with the Commonwealth to develop parameters for success of this program, including those surrounding the standardization of data collection, the process for identifying
and monitoring health and health care inequities, and the implementation of evidence-based interventions to reduce inequities.
Flexible Services Program
The MMS also supports the continuation of the Flexible Services Program (FSP), which offers nutrition or housing supports for members experiencing health-related social needs. We know the value of interventions such as the Food is Medicine plan and the
importance of housing security to people’s overall health and well-being. We are committed to working with the state to maximize access to services for vulnerable populations and addressing social determinants of health, which have a substantial impact
on people’s health, well-being, and quality of life.
The Medical Society promotes a comprehensive approach to health care that recognizes the importance of health-related social needs such as stability in nutrition and housing. Furthermore, it is critical to acknowledge how these needs have a disproportionate
negative impact on people of color. In Massachusetts, Black and Latinx people experience homelessness and food insecurity at rates far exceeding those for white individuals. The goods and support services provided by the FSP have positive impacts
on members’ health and costs of care. Expanding nutrition support services to a member’s household would help to maximize the benefits of these supports. The welfare of the family being critical to each member’s health, allowing FSP services to be
used for childcare allows vital support for families with children, permitting members to devote more time and effort to nutritional education and skill development. With regard to housing support services, expanding the definition of “chronically
homeless individuals” will give more people access to these tremendously helpful services, which work simultaneously to improve health and lower health care costs. Expanded opportunity for housing stability is particularly crucial for children’s educational
and emotional well-being.
Postpartum Coverage Expansion
The Medical Society additionally stands in strong support of extending the postpartum period of eligibility for services from 60 days to a full 12 months after birth. The Medical Society is committed to combating the rise in maternal morbidity and mortality
and the racial disparities therein. Inadequate postpartum care may contribute to persistent racial and ethnic disparities in maternal and infant health outcomes, and expanded MassHealth coverage in the postpartum period will help to improve these
longstanding inequities. A significant clinical paradigm shift in postpartum care has emerged emphasizing that postpartum care is an ongoing process that typically requires multiple visits and follow-up care that may last a year or even longer. Increasing
access to postpartum care is particularly important for those who experience pregnancy complications or have chronic conditions, such as cardiovascular disease, hypertension, or diabetes, which disproportionately affect people of color. Moreover,
access to behavioral health services for women experiencing postpartum depression – that may not be detected within the first two months postpartum – is essential to the success of mother-infant bonding and the health of the child. Medicaid-enrolled
pregnant individuals are more likely than women with private coverage to have certain chronic conditions, preterm births, or low birthweight babies, putting them at higher risk for poor maternal outcomes. The Medical Society sees this expansion in
coverage as fundamental to the success of maternal health care services provided through MassHealth and believes it necessary to advance maternal and infant health in our Commonwealth.
Coverage for Justice Involved Individuals
We are further heartened to see the request to expand MassHealth benefits to justice-involved individuals, providing much-needed, continuous health coverage for individuals who experience unique health challenges posed by entering, living in, and transitioning
from carceral settings. It is important to note that this expansion would protect not only incarcerated adults from losing their MassHealth benefits, but also incarcerated youth, who face an even greater health risk resulting from incarceration. Overall,
incarcerated individuals face drastic health disparities when compared to the general public in relation to health issues such as hypertension, asthma, substance use disorder, oral health, and mental health conditions. Compared to people who have
not been held in carceral settings, incarcerated individuals have a 12.7 times greater chance of death within the two-week period after their release, and they are over 120 times more likely to die of a drug overdose within that same timeframe. This
expansion of MassHealth coverage would help to reduce some of the health disparities felt by Black and Hispanic individuals, who are represented in the Massachusetts justice-involved population at rates of 7.5 and 4.3 times that of white individuals,
respectively. The Medical Society applauds the recognition that these vulnerable populations need MassHealth coverage during a most vulnerable and critical period.
Safety Net Sustainability and Near-Universal Coverage
The Medical Society additionally applauds the proposals aimed at sustaining safety net providers while at the same time advancing population health and health equity. Some of our Commonwealth’s most important resources for treating the most vulnerable
populations rely on funding to support their operational needs. Increasing the number of safety net hospitals eligible for this federal funding will create greater opportunity for physicians and other health care providers to treat a wider range of
patients with minimal negative financial impact, improving patient care and access, which ultimately betters the health of our Commonwealth. Additionally, toward that end, the Medical Society supports the efforts to maintain near-universal coverage.
Streamlining the user experience and providing greater supports for those at risk of disruptions in coverage while preserving affordability, coverage, and access to care through subsidies for lower-income enrollees will make it easier for Massachusetts
residents to identify and receive the care they need in a continuous and more reliable fashion.
Thank you for your consideration of these comments, and congratulations on an impressive and comprehensive waiver request. The Massachusetts Medical Society looks forward to remaining engaged with you to help provide the important physician perspective
as you refine this demonstration request.
View a PDF version of these comments here.
