Important MassHealth Changes, esp for Harvard Vanguard and Cambridge Health Alliance Patients

[siderea]

(Updated Dec 20)

If you are on MassHealth, and you get your primary care from either Harvard Vanguard (such as the one over the Au Bon Pain) or Cambridge Health Alliance (such as the one next to the defult Elephant Walk outside of Porter Square), there are some VERY BIG CHANGES coming with VERY IMPORTANT CONSEQUENCES.

If you are such a person, you should have received a package in the mail from MassHealth. It's a big white packet with a green stripe down one side. It says on the outside "This package contains important information about your health plan." Sure does. You'll want to read yours.

I just this afternoon called Harvard Vanguard, Cambridge Health Alliance, and MassHealth to get some clarity and make sure I understood the following correctly. (Edit to add 12/20: I have also now spoken to Neighborhood Health Plan, and Tufts Health Plan, which is running the ACO plans described below. I have also done a bunch of research online.)

From March 1, 2018 on, Harvard Vanguard (more accurately, the whole Atrius Health system, of which they're a large part) and Cambridge Health Alliance (edit to add: an a bunch of other, less local, healthcare systems) are cutting over to a new system for MassHealth patients. To continue being a patient there, you will have to be on one particular Atrius-specific or CHA-specific health insurance which no almost no other health care providers take.

That is, if you get your primary care through the Davis Square Harvard Vanguard, you will have to get all your other care from Atrius, too, and a select list of approved hospitals. Your Atrius-specific insurance will not cover care at specialists anywhere else.

This includes psychotherapy and psychiatry. For psychotherapy and psychiatry, there is an additional short list of external approved providers. Currently, if you are, say, a HV patient and MassHealth member on Neighborhood Health Plan, you may be seeing a psychotherapist or psychiatric prescriber at any of the many independent mental health clinics (such as the one I work at). That will may no longer be covered by your insurance come March 1. (Unless something changes between now and then.)

UPDATE: I was not wrong to observe that HV's Behavioral Health department definitely doesn't have the capacity to bring all its MassHealth patients in-house for psychiatry. MassHealth has picked 18 mental health and substance abuse treatment organizations that the ACO plans... do? must? can?*... cover.

For the record, not one organization I talked to, including the insurance company running this program (Tufts Health Plan) or MassHealth itself, could cough up this list, or even seemed to know it existed. At least at MassHealth, I got my call escalated to a second level member service agent, and they knew about the "community partners" (the buzzword for this) program, but didn't manage to tell me which organizations they were.

I found the information in a press release from Gov. Baker's office, from last August.

Here's the list of approved behavioral health (psychiatry, psychotherapy, and substance abuse treatment) providers:

Behavioral Health Network, Inc.
Behavioral Health Partners of Metrowest, LLC
Boston Health Care for the Homeless Program, Inc.
Clinical Support Options, Inc.
Community Counseling of Bristol County, Inc.
Community Healthlink, Inc.
Eastern Massachusetts Community Partners, LLC [Note: this may be a joint project of BayCove and Vinfen]
Eliot Community Human Services, Inc.
High Point Treatment Center, Inc.
Innovative Care Partners, LLC
Lowell Community Health Center, Inc.
Northeast Behavioral Health Corporation, dba Lahey Behavioral Health Services
Riverside Community Care, Inc.
South Shore Mental Health Center, Inc.
Southeast Community Partnership, LLC
Stanley Street Treatment and Resources, Inc.
The Bridge of Central Massachusetts, Inc.
The Brien Center for Mental Health and Substance Abuse Services, Inc.

My first thought looking at that list was to be shocked at what was missing: some of the giant mental health/social service agencies, like North Suffolk, Bay Cove, and Vinfen. But then some sleuthing of the organizations on the list that I didn't recognize turned up this 11/22 job listing at BayCove that says,

Bay Cove Human Services, Inc., and Vinfen Corporation, two leading Massachusetts human services organizations, seek a Project Manager for a new management company that will develop and deliver care coordination services to MassHealth members. The newly formed organization- Community Care Partners LLC (CCP), is the central management company for developing and delivering Behavioral Health (BH) Community Partner services [...] The Community Partners programs are key components of MassHealth’s delivery reform plans.

Well, there's no "Community Care Partners LLC" on the list, but there's a "Eastern Massachusetts Community Partners, LLC" on the list, which is incorporated at an address that is associated with Bay Cove, so maybe they're the same thing?

I haven't had a chance to check all the unfamiliar names, but maybe North Suffolk is hiding under one of them.

Also, the list doesn't mention Arbour. More on that below.

The upshot is: if you are a MassHealth patient at Atrius or CHA (or a bunch of other now ACO organizations) who is getting therapy or psychiatric med management from an organization not obviously on that list, the insurance you are going to have to be on for your primary care organization likely won't cover your mental health provider. It might, if they have some secret affiliation to one of those organizations. You'll have to ask them. Though they may not know. I don't think the clinic I work for is prepared to answer calls about this; I don't think they know what hit them.

UPDATE Dec 20, #2 I am now reading a document from the state for the Community Partners orgs themselves, which seems to be saying (see page 8) that only patients with severe mental health issues will be served by the Community Partners. I am back to suspecting that patients without such severe mental health issues won't be eligible for services from the Community Partners. That would explain some things like the Tufts and MassHealth agents not wanting to answer questions in the general for me, but only for specific patients – so some patients get qualified for psychiatric services from Community Partners, and others don't?

Or more accurately, there will no longer be one insurance plan that covers both Atrius doctors and independent mental health clinics. Likewise, there will no longer be one insurance plan that covers both Cambridge Health Alliance doctors and independent mental health clinics. If you are on MassHealth and get your primary care from Atrius (Harvard Vanguard) or CHA, (edit: and get mental health care somewhere else, that isn't conveniently covered by the above list) you will have to chose.

I don't know how this impacts methadone programs or other substance abuse treatment. CSAC, for instance, is run by Bay Cove, so I'm guessing that if Bay Cove is covered (an open question) they are too. But I think Habit OPCO is independent, so wouldn't be. For example. Our notorious neighbor, North Charles, which opened up that methadone program a few blocks away from Davis, apparently wouldn't be covered either.

Also, for the record, I called Tufts Health Plan and talked to one of the (alleged) specialist member service agents handling onboarding all these new MassHealth patients being converted to the ACO plans. I asked point blank some of the questions I pose here, such as available mental health services in-patient and out-patient and how BEST clearances work. The agent was clearly looking things up in her computer, and she was telling me things that, since I found that list, seem at odds with it, and sometimes contradictory to other things she told me. For instance, she told me that Arbour Hospital JP would be in-network for ACO plan members, but Arbour isn't on the list of approved Community Partners (nor is Universal Health Services, Inc., which owns them); at that point, she told me no outpatient Arbour facilities were coming up, but when I asked her to specifically search on outpatient for the Davis Square area, one Arbour Counseling Services location came up – the one in Woburn (I didn't even know they had a location in Woburn), but not the (T-accessible) one in Allston or in Medford. If you are a HV or CHA MassHealth patient, will your new insurance cover seeing an Arbour therapist? Or only therapists at some Arbour locations? No idea. Doesn't seem like Tufts Health Plan knows either. I am worried her searches were not specific to the new ACO plans, and she was getting results of facilities that take non-MassHealth Tufts insurance products, that aren't constrained to the approved Community Partner list.

(Oh, this is going to be hilarious: last I checked, HV Somerville had horrendous wait times for their Behavioral Health department, already. So now they're going to make all their MassHealth patients come in-house?)

I assume the same is true about physical therapy, but I know less about that ecosystem.

According to the press release, there are two sorts of Community Partners organizations: Behavioral Health (i.e. mental health and substance abuse) and "Long Term Services and Supports". This latter category has a different list of approved Community Partners. It's described as "organizations providing care coordination support for people with complex long-term services and support needs. This includes members with physical disabilities, traumatic brain injury, intellectual or developmental disabilities and others." I can't tell from that description whether these are organizations that offer physical therapy, or organizations that offer social workers that find you a physical therapist and book the appointments, or both.

I have no idea if or how this also applies to optical services. Last I checked, Harvard Vanguard's ophthalmology department served MassHealth patients, but their optical shop doesn't. So, if for that reason you were a Harvard Vanguard patient who decided to get your eye exams and glasses from, say, Harvard Sq. Eye Care down the Square across from Posto, or at the Parelli Optical in Porter, well, it looks like you won't get to do that any more.

Tufts Health Plan's agent told me that for MassHealth patients, this isn't covered by Tufts, but by MassHealth itself, so won't be changing. I don't actually believe this, not least because the goddamned Tufts page for the CHA plan explicitly says it covers "Eye exams, eyeglasses and contact lenses", and so does the one for Atrius, but also because that would mean part of those orgs (their ophthalmology depts) are not being covered by the same insurance as the rest of the org, which is kind of against the whole point of the ACO thing, but who knows?

If you are a MassHealth patient getting some of your health care at Harvard Vanguard and some of your health care elsewhere, you are (edit: likely) going to be forced to chose. Same with Cambridge Health Alliance. It's all or nothing: either you get all your routine care in-house (or from the short list of approved external vendors), or you give up Harvard Vanguard or Cambridge Health Alliance, and get your primary care somewhere else.

Also, apparently – and I haven't yet confirmed this – MGH will not be in-network for Atrius and CHA patients. The list of in-network hospitals for those plans includes Mt. Auburn, BMC, and BIDMC, but does not list Mass General. So apparently MassHealth Atrius and CHA patients will be losing access to MGH...? Not sure about this yet, but does seem to be what the paperwork is saying.

Also, the paperwork is unclear as to whether Atrius (Harvard Vanguard) patients will continue to have access to Somerville and Cambridge Hospitals, which are flagged as "CHA" in the list. I don't know if that's merely to identify those as CHA hospitals, or to indicate they'll only be available to CHA members.

Also, I have no idea how this will impact psychiatric emergency services or psychiatric hospitalizations. Right now, if you call the BEST hotline for suicidality or psychosis, and they decide you need to go to a hospital for psychiatric reasons, they require you to go to MGH for medical clearance. But MGH has been in-network for all insurance products known to human kind, because MGH. Now, if MGH is out-of-network for Atrius- and CHA- MassHealth patients, what does the BEST assessor do with them? Send them to MGH anyway? (Is there a provision for this? Or does a BEST call now come with a potential sky-high bill for out-of-network services?) Or will BEST be checking insurance status, and routing Atrius- and CHA- MassHealth patients to BMC? (They used to use BMC for medical clearance, then stopped, and I never got a straight answer on why.) Or some other hospital? I have no idea. I will be trying to get answers for this, but talking to MassHealth was not, shall we say, the most satisfactory customer service experience I've ever had.

Okay, I talked to Tufts about this, and apparently the in-network/out-of-network distinction is waved for emergency care. Maybe. Sort of. But the agent I talked to said that being taken to MGH on an emergency basis would be covered. I kind of believe her because she enriched her story with some account of the paperwork that the hospital would (have to) do to get paid by Tufts. Bureaucracy substantiates.

And does this mean that Atrius- and CHA- MassHealth patients will not have access to Arbour hospitals? Talk about your mixed emotions. Arbour is widely regarded as terrible, but the state keeps not shutting them down because there's not enough psychiatric hospital beds otherwise. Arbour is not on the list of in-network hospitals. So does this change mean Atrius- and CHA- MassHealth patients will have a much, much harder time finding in-patient psychiatric care if they need it? Or will get nailed with huge bills if they go to an Arbour hospital? It's not clear to me right now how any of this will work, but what I got on paper sure looks bad.

See above re mixed messages on Arbour. I'm optimistic that Arbour hospitals will, for better or worse, be covered, because there's not really another option. But I don't have a lot of of confidence in that prediction, not least because this whole reform thing was whipped together in the last 12 months – much of it not actually sorting out until so recently the ink is still wet on the contracts. Indeed, some of it may not yet be settled; on the Tufts website, the "Member Benefits" links for CHA and Atrius are trivially vague, the Member Forms link says "Coming Soon", and the agent I spoke to on the phone seemed reluctant to agree to ship me a policy document, all of which suggests to me that maybe they haven't finished writing it yet, maybe because they haven't entirely nailed down what all goes in it.

ETA 12/20 #3: Okay, yeah, the powerpoint previously mentioned literally has a timeline (page 30) showing that ACOs are to contract with Community Partners in December after the program launches. *rolls eyes*

While information is still coming in, right now, this all looks pretty bad. The nominal reason for the change is to move to an "Accountable Care Organization" payment model, which is supposed to control costs by incentivising health care providers to provide quality treatment over quantity treatment. But it sure looks like it's a cost-controling measure for MassHealth that works by limiting poor people's access to necessary healthcare services, by radically curtailing the number of in-network providers they have access to.

Thought everyone should know.

There's other bad stuff that ACO-style payment models tend to cause (I wrote about some research into that, back in August) but as to whether that's happening or going to happen here is more speculative. More info when I have it.

* Oooh, I just (12/20) found this powerpoint from an EOHHS open meeting with Community Partner orgs with a footnote that says of Behavioral Health (for patients with substance abuse or severe mental health issues) and LTSS services "ACOs and MCOs must delegate these functions to CPs (exceptions to be defined by EOHHS)" (emphasis in the original!) So... must, except not. So who knows?