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 Outcomes Davis, Stremlkis, Squires, Schoen
Poor Health Outcomes Davis, 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 2006 Principles
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 Reform Adapted 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 Overview Adapted from D. Berwick
ACA Overview Adapted 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 Overview Adapted from D. Berwick
ACA Overview Adapted 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
Make each point relevant to behavioral health audience

10. New Benefits to Massachusetts of the Affordable Care Act Shira Schoenberg, Affordable Care Act Brings Changes to the Massachusetts Health Insurance Market, 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 Law Chapter 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