Massachusetts policy makers are increasing their focus on behavioral health treatment and how this relates to overall state health care spending. This issue was heavily discussed at the Health Policy Commission's (HPC) annual Cost Trends Hearings on October 17th and 18th and during meetings throughout the year, reflecting the growing concern in Massachusetts health care.

In written testimony submitted before the Cost Trends hearings, both payers and providers noted their focus on integrating behavioral health into overall care. Payers such as Blue Cross Blue Shield of Massachusetts and Neighborhood Health Plan discussed partnerships with behavioral health providers as a way to increase the adoption of alternative payment methodologies (APMs). Various payers also mentioned behavioral health collaborations in their strategies to increase access to pharmacologic treatment for substance use disorder. Nearly all providers who submitted testimony identified their top strategies for integrating behavioral health with overall care, as well as any potential barriers. Many highlighted integrated behavioral health services models, increased use of telehealth, and universal screenings as their top strategies to enhance this area. Providers pointed to insufficient reimbursements and incentives and the lack of publicly available claims data as the major barriers to integrating behavioral health.

Throughout the two-day hearings, a number of speakers and witnesses emphasized the importance of meeting behavioral health needs. In his opening remarks, HPC Chair Stuart Altman highlighted how this is a topic of particular interest for the Commission, and that true health care services require a broad look into social and behavioral health conditions.

Representative Jeffrey Sanchez, House Chair of the Joint Committee on Health Care Financing, also discussed this topic in his opening remarks, stating that Massachusetts is leading the pack in behavioral health treatment. Sanchez noted how this impacts the state's ability to adhere to its cost growth benchmark. He also identified ongoing problems in behavioral health, such as patients with behavioral health conditions boarding in emergency departments because they have nowhere else to go, and the continuing separation of behavioral and physical health treatment.

The Cost Trends hearings featured a witness panel titled "Strategies to Address Social and Behavioral Health Needs" to discuss two of the issues that pervaded both days of the Hearing. The five panelists were from organizations with a long history of focusing on the social determinants of health, and included: Kate Walsh, President and CEO of Boston Medical Center; Dr. Toyin Ajayi, Chief Medical Officer of Commonwealth Care Alliance; Manny Lopes, CEO of East Boston Neighborhood Health Center; Dr. Elsie Taveras, Chief of the Division of General Pediatrics at Massachusetts General Hospital; and Spiros Hatiras, President and CEO of Holyoke Medical Center.

Throughout the panel discussion, the witnesses addressed the models and efficiencies associated with effectively addressing social and behavioral health determinants. Dr. Taveras opened the panel discussion by saying that the ACO model will not offer sufficient behavior health funds, and the health care community has to think about other creative models and funding mechanisms. She also addressed the issue in relation to children's health, as the pediatrics community has been having conversations on behavioral health issues for years because children are maximally dependent on their environment and their parents. Ajayi and Lopes further highlighted the need for the resources and investments needed to effectively address social and behavioral health determinants, with Ajayi advising that it is important to have the resources and alignments in place to build partnerships with small groups on the delivery side.

Commissioner Carole Allen asked the panel for their thoughts on using integration models that focus on hiring professionals from the communities being served. Walsh said that integration is important for some patients, but not all. She said the health care community needs to identify who needs social and behavioral health services and find a way to provide them with those services. Ajayi pointed out that ways to address costs and provide care vary among populations.

In terms of efficiency, Commissioner David Cutler asked the panelists if the issues they are encountering in addressing social and behavioral determinants of health stem more from a lack of funding for the upfront costs or from a lack of experience in the area. Walsh said the problem is a little bit of both -- there is inadequate supply in some communities, and there is also the problem of culture clash.

Telemedicine can also play a great role in addressing behavioral health. The integration of telemedicine, particularly telepsychiatry, was another major trend at the hearings. As the Commonwealth seeks to improve mental and behavioral health services and their costs, telemedicine can enhance the system as providers can see patients at home and easily follow up for post-acute care. Telemedicine has played a growing role across the nation in helping address behavioral health needs, particularly with the rise of opioid addiction and substance abuse.

Prior to the Cost Trends hearings, a report released by the Center for Health and Information Analysis (CHIA) this past August focused on Behavioral Health & Readmissions in Massachusetts Acute Care Hospitals. The report highlighted an ongoing problem in the state, as there is a growing recognition that patients with comorbid behavioral health conditions may have a higher than average risk of hospital readmission. Hospitalized patients with any behavioral health comorbidity were 77% more likely to be readmitted than those without behavioral health comorbidity, 20.2% vs. 11.4%. Reducing avoidable readmissions is a key factor of numerous payment reform and delivery system transformation efforts, particularly as Massachusetts has a comparatively high rate of hospital readmissions that is driving health care costs.

At a November 15th meeting of the HPC Advisory Council, many members carried the conversation from the Cost Trends hearings and emphasized the need for behavioral health integration. Massachusetts Health and Hospital Association President and CEO Lynn Nicholas stated that we have to find ways to allocate more resources to behavioral health, as this will drive costs down more than anything else. David Matteodo, Executive Director of the MA Association of Behavioral Health Systems, Inc., agreed that he hopes the HPC focuses more on integration. HPC Executive Director David Seltz stated that the commitment is there, and highlighted the increased time and energy put into integrating behavioral health since Secretary of Health & Human Services Mary Lou Sudders was appointed.

Integrating behavioral health will continue to be of great importance for Massachusetts and other states across the nation. At the federal level, a bill pending before Congress championed by Congressman Tim Murphy may pass before the current session ends. However, mental health may not be as great of an issue for PresidentElect Donald Trump's Administration as it would have been with a different election outcome. While it will still be a great focus for state healthcare conversations, the spillover effect of action at the federal level involving the future of the Affordable Care Act will be more likely than direct action regarding behavioral health.