Reducing Human Pain and Suffering: Is That Enough Return On Investment?

1. Reducing Human Pain and Suffering: Is That Enough Return On Investment? Marcia Fowler Commissioner Massachusetts Department of Mental Health

2. Outline • Overview • Contrasts and Similarities • 2006 Massachusetts Healthcare Reform • 2010 Affordable Care Act • 2012 Cost Containment in MA • Parity

3. Overview—Why Reform? • Too many people lack health care coverage • 55 Million under age of 65 not insured (1/5 for that age group) • US healthcare spending is unsustainable • 20% of the GDP by 2020 • Despite high spending, US healthcare outcomes are poor • Our system emphasizes treatment not prevention • Health disparities exist among various populations

4. Poor Health OutcomesDavis, Stremlkis, Squires, Schoen. Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally 2014 Update. The Commonwealth Fund, June 2014 • Commonwealth Fund Study 2014 • US compared with 10 other industrialized nations (e.g. UK, Switzerland, Sweden, Australia, Germany ) • US ranks last in overall healthcare measured by • Quality • Access • Efficiency • Equity • Health indicators (e.g. infant mortality) • Racial and ethnic health disparities

5. Chapter 58 of 2006“An act to provide access to affordable, quality, accountable health care” • The 2006 Massachusetts Health Care Reform Law (Romney Care) • Achieve near universal coverage for all MA residents • Health care and coverage that is affordable and high quality • Reform process that is open to transparency, accountability and improvement

6. Chapter 58 of 2006Principles • Shared responsibility for expanding access to health coverage (individual, employer, government) • Public funded programs to subsidize insurance for low income residents • Private sector will shift ‘free care’ to subsidizing insurance coverage • Employers obligated and mandated to make it easier for employees to purchase insurance • Individual mandate to have insurance • Coverage must be creditable • Benefits must encourage preventive care and provide financial security when medical care is needed

7. Benefits of Massachusetts Health Care ReformAdapted from Focus on Health Reform, The Henry J. Kaiser Family Foundation, Massachusetts Health Care Reform: Six Years Later, 2012 • Commonwealth Health Insurance Connector • Health insurance exchange website • Both subsidized and non-subsidized private health insurance • Insurance Market Reforms • Reforms to the private insurance market – defined coverage and affordability standards • Guaranteed issue – no denials for pre-existing conditions • Community rating – can’t charge more based on health status or claims history • MassHealth Expansion • Enrollment limits raised for the CHIP program (300% FPL) • Enrollment caps raised for existing Medicaid programs for adults

8. ACA OverviewAdapted from D. Berwick. “The Triple Aim: Health, Care, & Cost: Public Health & the Health Care Transition”: June 2012/APHA meeting A. Insurance Reform: More people covered Medicaid expansion for all below 133% FPL Insurance exchanges for ease of access and purchasing Family coverage until age 26 Guaranteed Issue prevents denial of pre-existing conditions Individual Mandate More benefits and protections Essential benefits defined and include MH & SA Preventive services covered – no copay No lifetime/annual limits on essential benefits Lower costs (consumers and government) Exchange subsidies Medical Loss Ratio (80-85% of premium $$ spent on care) Premium rate review (10% or more increase) published Prescription drug rebates (Medicare D) during “donut hole”

9. ACA OverviewAdapted from D. Berwick. “The Triple Aim: Health, Care, & Cost: Public Health & the Health Care Transition”: June 2012/APHA meeting B. Health System Reform: Improved quality and efficiency Accountable Care Organizations Medical Homes pilots Incentive payments for quality not quantity Dual Eligibles care coordination Stronger workforce and infrastructure Community & school based health centers Medicare/Medicaid provider payments for PCPs NHSC loan repayment program increased Greater focus on public health and prevention Prevention & Public Health Fund Community Health Needs Assessments Public education campaigns (prevention & wellness) Nutritional labeling

10. New Benefits to Massachusetts of the Affordable Care ActShira Schoenberg, Affordable Care Act Brings Changes to the Massachusetts Health Insurance Market, http://www.masslive.com/politics/index.ssf/2013/09/affordable_care_act_brings_cha.html, September 25, 2013. • Plan Benefits • Young adults may remain on their parent’s plan until age 26 • The “donut hole” in Medicare drug plans will be closed • Preventive care will be available with no co-pays or deductibles • Subsidies available to those earning up to 400% of the FPL • Eligibility for everyone earning less than 133% of the FPL • Financial Benefits • $200M in federal matching funds to cover low income individuals • Could grow to $400M over the course of the year (2014) • $270M in federal grants to implement the new law

11. Increased Healthcare Costs • MHR did not include cost containment measures • MA spends 15% more per capita on healthcare than national average • MA average monthly insurance premium is highest in nation at $437 per person • Fee for service payment methods dominate the market

12. MA Cost Containment LawChapter 224 of 2012 • Commissions to monitor and enforce healthcare cost growth targets • Adoption of alternative payment methods (especially in Medicaid) • Increased price transparency for consumers • Focus on wellness & prevention • Expansion of primary care workforce • Health Planning Council – State Health Plan • Medical Malpractice Reforms (“182 cooling off” & apology) • Mental health parity and Integration

13. Behavioral Health Integration Task Force 2013 Recommendations • Encourages diverse models of integrated care • Reimburse BH screening for all children • Peer supports as a standard of care • Adequate funds for BH services • Compliance with parity laws • Insurance company transparency • Eliminate prior authorization • Privacy issues • Person and family voice and choice • Education and training

14. Parity • Equal access to treatment, screening and prevention • Transparency • Funding • Treatment limits or denials • Population disparities • Civil rights issue, not stigma

15. Next Steps • Payment Reform • Comprehensive Care Coordination • Workforce and Peers