Commonwealth of Massachusetts
Executive Office of Health and Human Services

State Innovation Model Overview

February 11, 2014

Agenda

•	 SIM Overview/Updates
•	 Primary Care Payment Reform
•	 E-Referral 
•	 Massachusetts Child Psychiatry Access Project

State Innovation Model Testing Grant

•	The SIM grant is a competitive federal funding opportunity for states to design and test multi-payer payment and delivery models that deliver high-quality health care and improve health system performance
•	In February 2013, Massachusetts was one of six states awarded a model testing grant (other states are Arkansas, Maine, Minnesota, Oregon and Vermont)
•	Grant activities focus on implementing alternative payments as envisioned by Chapter 224, and creating the foundational tools to support delivery system change
•	Total grant award is for $44 million over 3.5 years
•	Massachusetts recently completed the implementation phase and received the “green light” to start Year 1

SIM and Chapter 224

•	Chapter 224 defines a clear vision for health reform in the state and provides tools to achieve that vision
•	SIM supports and accelerates progress, by, for example:
•	Supporting transition to alternative payments
•	Strengthening IT infrastructure
•	Building on initiatives to align on quality measurement

Application Timeframe

•	Application submitted September 2012
•	Awards announced in February 2013 
•	Massachusetts awarded $44 million over 3.5 years 
•	Implementation phase April 1, 2013 through December 31, 2013

SIM and Chapter 224

•	Chapter 224 defines a clear vision for health reform in the state and provides tools to achieve that vision
•	SIM supports and accelerates progress, by, for example:
•	Supporting transition to alternative payments
•	Strengthening IT infrastructure
•	Building on initiatives to align on quality measurement

SIM Grant Projects

•	What is our goal?
o	The Triple Aim: Better population health, better experience of care, lower costs
•	How do we do it?
o	Payment Reform
o	Delivery system transformation
o	Cost and quality accountability
•	How does SIM help us get there?
o	Medicaid’s Primary Care Payment Reform Initiative
o	The Group Insurance Commission’s value based purchasing initiative  
o	Provider portal on the APCD
o	Adoption of the Health Information Exchange
o	Data infrastructure for LTSS Providers
o	Electronic referrals to community resources
o	Access to pediatric behavioral health consultation
o	Linkages between primary care and LTSS
o	Technical assistance to primary care providers
o	HIE functionality for quality reporting
o	Statewide quality measurement and reporting 
o	Payer and provider focused learning collaboratives 
o	Rigorous evaluation 

SIM Grant Projects

•	What is our goal?
o	The Triple Aim: Better population health, better experience of care, lower costs
•	How do we do it?
o	Payment Reform
o	Delivery system transformation
o	Cost and quality accountability
•	How does SIM help us get there?
o	Medicaid’s Primary Care Payment Reform Initiative
o	The Group Insurance Commission’s value based purchasing initiative  
o	Provider portal on the APCD
o	Adoption of the Health Information Exchange
o	Data infrastructure for LTSS Providers
o	Electronic referrals to community resources
o	Access to pediatric behavioral health consultation
o	Linkages between primary care and LTSS
o	Technical assistance to primary care providers
o	HIE functionality for quality reporting
o	Statewide quality measurement and reporting 
o	Payer and provider focused learning collaboratives 
o	Rigorous evaluation 

Agenda

•	 SIM Overview/Updates
•	 Primary Care Payment Reform
•	 E-Referral 
•	 Massachusetts Child Psychiatry Access Project

Overview of Primary Care Payment Reform

•	Primary Care Payment Reform (PCPR) is MassHealth’s proposal for testing an alternative payment methodology and transforming the way healthcare is delivered 
•	The initiative aims to enhance coordination across providers, increase accountability for the total cost of care across all players, integrate behavioral health services and contain costs  
•	PCPR advances the Administration’s commitment to building a strong primary care foundation and to support primary care as a key to achieving health reform
•	The payment mechanism that supports that delivery model is a comprehensive primary care payment combined with shared savings +/- risk arrangement and quality incentives

Primary Care Payment Reform: Payment Structure

Comprehensive Primary Care Payment: 
•	Risk-adjusted capitated payment for primary care services 
•	Option to include some behavioral health services

Quality Incentive Payment
•	Annual incentive for quality performance, based on primary care performance

Shared savings payment
•	Annual payment to primary care providers based on savings on non primary care spending, including hospital and specialist services

The payment structure will not change billing for non-primary care services (specialists, hospital) 

Update on PCPR

•	Participation in PCPR was finalized in December 
•	30 Primary Care Clinicians (PCCs) partnered with MassHealth in this initiative for the first program year 
•	Our Participants are diverse in terms of size, location, provider type and participation in MassHealth’s prior three year demonstration: the Patient Centered Medical Home Initiative (PCMHI)
•	Of the 30 Participants, 10 have elected to include certain outpatient behavioral services as part of their monthly capitation payment   
•	January and February includes a Soft Launch with a series of learning sessions to help prepare our Participants based on lessons learned from PCMHI 
•	The capitation payments and initiation of the performance periods for the quality incentive payments and shared savings payment will start in March 2014

Soft Launch Calendar

January:
•	In-person Kick-Off Meeting 
•	Learning Collaborative Meeting for Executive Leadership  

February
•	Two Quality Webinars 
•	Data Reports Sub-group Webinar 
•	Dissemination of March CPCP rates 
•	Written Q&A on claims processing and financing 
•	Data Reports Launch Webinar

March
•	Weekly office hours 

The Soft Launch calendar and the payment Go Live is supported by the internal work of the PCPR team. Activities include: streamlining communication, working with MMIS and Accounting units and finalizing March rates with our actuaries

Next Steps

•	Payment model Go-Live on March
•	Initiation of PCPR Office Hours 
•	Finalization of PCPR Evaluation dashboard 
•	Launch of raw claims and quality report sub-groups 
•	Meeting for Second Learning Collaborative  

Agenda

•	 SIM Overview/Updates
•	 Primary Care Payment Reform
•	 E-Referral 
•	 Massachusetts Child Psychiatry Access Project

Overview of e-Referral Program

e-Referral program will create and pilot an open-source, bi-directional referral system to formalize community-clinical linkages
•	The year 1 pilot sites have been selected & work has started to connect these CHCs to 6 community-based organizations 
•	The Massachusetts League of Community Health Centers are essential partners in this effort for EMR integration, clinical workflow, & evaluation
•	This effort is also aligned with the Prevention & Wellness Trust Fund (2 of our initial pilot sites are also PWTF awardees)

Promoting Community-Clinical Linkages

Create
e-Referral requires a bi-directional electronic linkage as well as conversations between organizations to initiate community-clinical linkages

Evaluate
e-Referral system can provide baseline reports on # of referrals, # of services received, and a variety health outcomes such as # of pounds lost
When integrated with the EHR, health systems can evaluate the impact of these community programs on population health

Sustain
Once installed, the e-Referral system can be modified to incorporate additional types of community resources

Using the e-Referral software and EHRs, community-based organizations can make the case for clinically meaningful and cost-effective programming

Pilot CHCs & Community-based Organizations

My Health, My Life
 Coalition

Manet CHC

Harbor Health
 Services, Inc.

Brockton
Neighborhood
Health Center

Tobacco Quitline
(all)

VNA Hospice Care

Brockton VNA

Message Transmitted to 
Universal Translator
directly or through 
MassHIway
All transmissions:
 -Secure (HL7) 
        -HIPAA compliant

Feedback Data  

Referral Data Items

Referral Data Items

Feedback Data  

SS Elder Services

SS YMCA

e-Referral Implementation Timeline

IT Initiation
& Elaboration Complete
September 2013

e-Referral Gateway
Prototype User Testing 
September 2013

CHCs apply for e-Referral
September 2013

IT team formed
May 2013

Use-Case Development
June- August 2013

Referral data elements
finalized
March 15, 2013

Coding of 
Open-source system
January-May 2014

Initial work with CHCs
and CBOs begin
February 2014

e-Referrals go live
in initial sites
June 30, 2014

Proof-of-Concept Testing
September-December 2013

Evaluate initial
e-Referral launch
September 2014

EMR integration
June 1, 2014

Grant Starts
April 2013

Next steps for the Pilot Sites

Series of meetings to work on both the technical and the business sides of the project
•	Meeting with the community-based organizations to finalize data elements and referral types
•	Working with the Mass League and CHCs to develop a roll-out plan for each clinical site
•	Working with IT lead to make the necessary changes in the EMR 
Goals for year 1
•	 3 CHCs initiating referrals to multiple community-based organizations & receiving feedback reports from those organizations into the electronic medical record

Agenda

•	 SIM Overview/Updates
•	 Primary Care Payment Reform
•	 E-Referral 
•	 Massachusetts Child Psychiatry Access Project

Massachusetts Child Psychiatry Access Project (MCPAP): Overview

•	MCPAP is a key component of the SIM grant’s objective to transform the delivery system by promoting pediatric behavioral health integration
•	MCPAP Model: Statewide network of six regional child psychiatry consultation teams (hubs) that support pediatric primary care practices in addressing behavioral health needs of their patients
•	95% of pediatric practices are enrolled in MCPAP, covering 98% of children in the Commonwealth
•	Services available regardless of child’s insurance status.
•	Regional hubs include child psychiatrists, licensed clinical social workers, and care coordinators
•	Provide telephone-based psychiatric and mental health consultation between pediatrician and child psychiatrist, and referral to community behavioral health resources
•	Outcome: By enhancing pediatrician’s ability to address children’s mental health needs, MCPAP mitigates the shortage of child psychiatrists
•	MCPAP is funded by the Department of Mental Health (DMH) and administered by Massachusetts Behavioral Health Partnership (MBHP)

Massachusetts Child Psychiatry Access Project (MCPAP): Overview

MCPAP Case Study
PCP calls MCPAP about a 14 year old girl who screened positive for depression in well child visit
PCP seeking advice on whether to prescribe SSRI
•	MCPAP psychiatrist recommends that PCP talk with girl to find out what might be causing depression, whether she is suicidal, drug/alcohol hx, trauma hx, etc. in order to inform tx options
•	MCPAP psychiatrist recommends psychotherapy in addition to SSRI
•	MCPAP care coordinator follows up with parent to assist with therapy referral and with PCP to update on 1st appointment timing

Massachusetts Child Psychiatry Access Project (MCPAP): Grant Activities

•	Expand real-time access to MCPAP psychiatrists via telephone to full-time coverage
•	Provide pediatric psychiatry consultation to pediatricians Monday – Friday, 9 am – 5 pm, with response time within 30 minutes
•	Provide education and enhanced consultation to primary care providers (PCPs) regarding adolescent substance use
•	Increase utilization of MCPAP among PCPs
•	Develop sustainability strategies for MCPAP including how to align MCPAP with emerging primary care-behavioral health integration models (e.g., health homes)
•	Evaluate outcomes that result from MCPAP SIM grant activities with particular focus on substance use enhancements

Massachusetts Child Psychiatry Access Project (MCPAP): Substance Use Enhancement Activities

•	DMH and MCPAP are partnering with the Center for Adolescent Substance Use Research (CeASAR) at Boston Children’s Hospital and the MA Department of Public Health to:
•	Conduct a pediatrician needs assessment/survey to explore current use of adolescent substance use screening tools and interventions (survey is a repeat of 2008 DPH survey)
•	Update and disseminate the DPH Screening, Brief Intervention, and Referral to Treatment (SBIRT) toolkit for pediatricians informed by survey findings
•	Conduct pediatrician trainings on SBIRT for adolescent substance use
•	Enhance the capacity of the MCPAP regional hubs to provide adolescent substance use consultation to pediatricians 

Massachusetts Child Psychiatry Access Project (MCPAP): Utilization Activities

•	A MCPAP Utilization Advisory group has begun meeting.
•	It includes a child psychiatrist/researcher with expertise in pediatric behavioral health integration and a pediatrician/researcher from Massachusetts General Hospital. 
•	Advisory group goals are to: 
•	Identify known determinants of MCPAP utilization
•	Design and implement additional assessment of MCPAP utilization
•	Develop strategies that MCPAP hubs can implement to increase utilization
•	For example, one strategy being considered is using APCD pharmacy claims to identify PCPs who are very high or low prescribers of psychotropic medications (relative to their peers) and infrequent MCPAP utilizers.
•	This group of PCPs could be targeted for MCPAP outreach and education to increase their MCPAP utilization, when appropriate.

Massachusetts Child Psychiatry Access Project (MCPAP): Sustainability Activities

•	Financial sustainability:
•	Given current FY increase to MCPAP base budget and new legislative mandate to surcharge commercial payers, sustainability activities will focus on long-term sustainability of emerging MCPAP primary care initiatives (e.g., substance use enhancements, early childhood mental health, perinatal mental health, etc.)
•	Programmatic sustainability: 
•	A MCPAP Sustainability Steering Committee comprised of public and private payer representatives will begin meeting in Spring 2014.
•	The committee will identify MCPAP's potential role in behavioral health integration models under payment reform (e.g., medical-provided behavioral health care, co-location, reverse co-location, etc.)

Conclusion and Next Steps

•	Will provide updates on different projects at next meeting (will rotate topics)
•	Expecting baseline assessment to be done by federal contractors in near future
•	Appreciate your input to all projects as well as to SIM grant overall

For more information:
•	http://innovation.cms.gov/initiatives/state-innovations/
•	http://www.mass.gov/eohhs/gov/commissions-and-initiatives/state-innovation-model-grant.html
•	SIMgrant@state.ma.us