Leaders see rising need in Massachusetts for primary care and mental health care

Massachusetts must invest in primary care and mental health, leaders testified at the state’s annual hearing on trends in health care costs, which explored challenges and innovative solutions in the field.

“We must include mental and behavioral health in our coverage,” said Massachusetts state Senate President Karen Spilka. “The opioid crisis was the result of unmet mental health need. Our prisons provide a lot of our mental health care.’’

The Health Policy Commission, which sponsors the hearings, last week put out its annual report card on the state’s efforts to rein in costs, which rose 3.1% in 2018. While spending here rose more slowly than in the nation as a whole, cost pressures are building and more of the burden of paying medical bills is falling on consumers.

Gov. Charlie Baker has proposed legislation that would require hospitals and insurers to increase spending on primary care and mental health by 30% over three years, arguing it will lead to better outcomes and lower costs.

“For far too long we’ve neglected preventive services that keep individuals out of our emergency rooms,” Baker said. “Our system rewards providers that offer bigger services that are more technologically advanced. It does not reward providers that offer primary care and behavioral health.”

A rise in need for mental health services

According to a Blue Cross Blue Shield of Massachusetts Foundation report, nearly 57% of adults age 19 to 64 who sought mental health or substance use disorder services had trouble finding a behavioral health provider.

The state’s largest insurer, Blue Cross Blue Shield of Massachusetts saw an 18% increase in the number of members accessing mental health services and a 10% increase in the number of members accessing substance use services between 2016 to 2018.

To meet the behavioral health needs of all its members, Blue Cross allows an unlimited number of therapy sessions for many behavioral health conditions and does not limit the length of time for an individual therapy session.

A focus on community care

At the cost trends hearing, hospital chiefs including Dr. Anne Klibanski, chief executive officer of Partners HealthCare, Sandra Fenwick of Boston Children’s Hospital and Dr. Kevin Tabb of Beth Israel Lahey Health said they were putting more resources into sites away from downtown Boston in a bid to lower costs and cut down on unneeded emergency room visits.

“We are shifting care to more cost-effective sites,” Tabb said. We are sending more people to community hospitals. We are adding urgent care to cut down on emergency visits.’’

“We have invested in both primary care and behavioral health and we will continue to do so,” Klibanski testified. “We are moving care out of the academic medical centers to community and ambulatory sites.”

Those words did little to satisfy some of the commissioners, who noted that hospitals keep getting more expensive, even after mergers that were aimed at wringing out savings. Hospital spending increased 3.7% in 2018.

“Costs keep going up,’’ said David Cutler, a member of the commission and a professor at Harvard. "The quality is good, but it is not getting better.”

New payment models

Blue Cross has long rewarded hospitals and clinicians for constraining costs and improving quality.

“We are proud of the work we have done around innovative new payment models that invest in primary care and behavioral health,” said Richard Lynch, Blue Cross’s chief operating officer, who participated in a panel discussion at the hearing.

Blue Cross is a leader in value-based contracts, which provide groups of doctors with a pool of money to treat patients and the flexibility to provide care as they see fit. If they meet targets for cost control and quality – such as strong records of diabetes management, for example – they are rewarded with extra payments. In practice, the contracts result in a greater emphasis on primary care because that approach leads to better results and lower costs, findings that have been backed up by academic studies.

The model, a shift from the traditional fee-for-service system that rewarded doctors for the procedures and tests they performed rather than quality of care, has been embraced by many clinicians, according to testimony at the hearing.

“Fee for service doesn’t work for our model,’’ said another member of the panel, Dr. Jeffrey Greenberg, the co-founder of Firefly Health, an innovative primary care practice based in Wellesley that contracts with Blue Cross.

“The value payments systems allow us to concentrate on cost and quality and select high value specialists,” Greenberg said. “We have a fully integrated model and many mental health issues can be handled by our team.’’

Greenberg noted he and his colleagues frequently use video conferencing and text messaging to communicate with patients and rely heavily on nurse practitioners, social workers and health coaches.

The team approach, which he says delivers good care at reasonable costs, couldn’t happen without the value contract. And the payment model allows the practice to embrace a tech-focused communications model.

“There is no medical code,” he noted, “for text messaging.”

A strong record

Massachusetts has long outpaced national standards on health care: A landmark health care reform law was signed in 2006, and today, more than 97% of residents have insurance, the highest rate in the nation. The state has some of the country’s most impressive public health rankings on measures of mortality, adult obesity, smoking, suicide rate and infant mortality. And every year since 2010, Massachusetts has outperformed the national average in constraining cost growth.

_{PHOTO BY MICHAELGRIMMETT}