Why we need to reorient our health care system

More emphasis need on primary care, behavior health, addiction, geriatrics

The following is the testimony Gov. Charlie Baker delivered before the Legislature’s Committee on Health Care Financing on Monday.

FOR THE PAST 50 years, the US health care system has been focused primarily on promoting and supporting the technological advancement of medicine. That focus has cured disease, enhanced therapies, and saved lives. But as that focus – and the success it has achieved – has dominated what and how we pay for health care, we have failed to appreciate the changing nature of illness and the systemic gaps in care delivery that have been created by this approach.

While many people would argue that the fundamental problems with our health care system are rooted in some provider organizations being paid too much, and others being paid too little, we would argue the problem is more fundamental than that.

Our health care system rewards those providers that invest in technology and transactional specialty services, at the expense of those who choose to invest in primary care, geriatrics, addiction services, and behavioral health care. Simply put, the care delivery and financing system we have today, which was built on the Medicare fee schedule developed 50 years ago, is not designed to take care of the people and the patients we have become and our health care needs in the future.

We pay for a system that is built on transactions and technological advances, not on collaborative care delivery, therapeutic support, or a combination of both.

While technological advances remain a critical component of delivering effective health care, a 21st Century health system should presume that collaboration and time are at least as important as technology, and that for many people, physical and mental health are related.

It should reward providers and provider organizations that invest in a comprehensive set of physical and behavioral health services and understand that population-based health management requires time and connection.

Solving this problem at the state level is complicated by the overarching role played by public and private national payors in health care in this country. For the most part, national payors, including Medicare, use payment policies that favor technology and transactional medicine at the expense of primary care, mental and behavioral health, addiction services, and, ironically, geriatrics.

Almost all providers and payors build their financial models and their operations using the Medicare fee schedule as their baseline.  This makes any decision to deviate from that model – for example, to offer more mental health services – extremely hard to do.

The bill I am here in support of today is designed to create positive financial incentives for health care providers and insurers to rethink their service delivery and investment decisions. Our proposal establishes a primary care and behavioral health spending target to reorient the way insurers and health care providers invest in these services that are underfunded by today’s payment models – and incorporate these services more directly into their care delivery strategies.

Specifically, our proposal sets a target of 30 percent growth in these areas over the next three years while requiring that overall health care spending remain within the confines of the health care cost growth benchmark.  It also gives providers and insurers flexibility with respect to how they meet that target.

On paper, for example, this means a payer that spent $100 million on these services in the aggregate in 2019 would have to increase that to $130 million by the end of 2024.  Overall, this proposal would require an additional investment in primary and behavioral health care of about $1.4 billion over the next three years.

But what does this math equation mean for the residents of the Commonwealth who are tired of waiting 6 to 12 months to see a primary care physician, who must pay out of pocket if they are able to find a behavioral health specialist, or who have no other avenue but an emergency department to access mental health treatment?

It means our health care system is going to need to engage differently to achieve this target:

Insurers will be incented to increase their rates of reimbursement for behavioral health care and expand their networks – in turn their members will have access to more in-network providers and services, so they are not left paying out of pocket privately or resorting to the emergency room for treatment.

Provider organizations will be incented to expand telehealth capacity and increase access to their practice sites, through extended evening and weekend hours – this means their patients won’t have to wait months to access these essential services that are fundamental to keeping people healthy and out of the hospital.

In addition, our proposal establishes a Primary Care and Behavioral Health Equity Trust Fund; the fund will provide money,  through MassHealth rates, to group practices, community mental health clinics, SUD outpatient providers, and other primary care and behavioral health providers serving Medicaid members.

Approximately 20 percent of the funds will be earmarked for targeted grant-funded initiatives in equity communities such as cancer screening clinics, improving language and disability access among ambulatory settings, and patient and community education on the de-stigmatization and availability of mental health and SUD services in high-need communities.

This fund will help increase access to these critical services and level many of the inequities in our health care system brought to light in the pandemic.

Our legislation also includes several other reforms to promote behavioral health parity – a goal we all share – to ensure behavioral health is treated the same way it treats physical health, including:

A requirement that insurers apply equal rates of reimbursement for certain office visits – whether provided by primary care providers or licensed mental health professionals and a requirement that insurers reimburse certain mental health clinicians in training, consistent with policies that MassHealth already has in place.

These proposals double down on our commitment to behavioral health reform and complement the work underway to implement the Behavioral Health Roadmap which outlines tangible ways we can increase access to these services.

Our FY23 budget proposal includes $115 million to implement that plan, including funding for:

  • A new, centralized, staffed Behavioral Health Help Line available 24/7 as of next January, to provide live support, clinical assessment, and connection to the right mental health and addiction treatment in real time.
  • Readily available outpatient evaluation and treatment through primary care, supported by new reimbursement incentives, as well as same-day evaluation and referral to treatment at designated community behavioral health centers throughout the Commonwealth. These designated behavioral health centers will be announced in June 2022 and come online in January 2023.
  • And truly 24/7 mobile crisis services.

The reforms we’re filing today will build on this work and further promote increased access to behavioral health and primary care.These reforms are systemic – designed to address the underlying challenges the system faces as we seek to work together to improve access to behavioral health and other critical services that our residents need.

Meet the Author
We know that our partners in the Legislature agree about the need to promote access to behavioral health care services. We believe this bill represents an opportunity to make fundamental changes to make that happen.

Charles Baker is the governor of Massachusetts.