2022-04-11 00:00:00 - Joint Committee on Health Care Financing
2022-04-11 00:00:00 - Joint Committee on Health Care Financing
SHOW NON-ESSENTIAL DIALOGUE
12 oh one. And out of respect for everybody who is here to testify, we're going to begin these hearings, pretend this is a gamble. Okay, hearing this committee
public hearing for the joint committee on health care financing will come to order
um before we go on, I just would like to remind the members of the committee and those participating on the team's virtual platform to mute your microphone at this time, unless you're recognized to speak. I would also like to remind people that when you have your video on we can see you, so if you47 start moving around or talking on the phone or getting lunch we can see you. So I ask that you be cognizant of that and if not turn your video off because it can be really distracted for the person who's um testifying
welcome everybody. My name is Cindy Friedman and I am the67 senate chair of this committee. I'm joined by my colleague and house co chair Representative john Lawn we are here today with members of the joint committee um uh Chair Lawn I'd like to introduce you and introduce so that you may introduce the House members in attendance.
Mhm Great, thank you Jeff Friedman and good afternoon everyone she said I'm john Lawn the House Chair of healthcare financing and I welcome all of you here today to testify on the act investing in the future of our health. Um and we look forward to hearing from all of you who are here with your passion to improve health care for all the residents in the commonwealth. Um so I'd just like to introduce my um House members of the committee. I have House Vice Chair J Livingstone here. Representative Duffy Representative Murray, Representative Diggs Representative meritorious and representatives Sabadosa has joined us so far.
Thank you today. The committee with her testimony on legislation pertaining to Senate bill 2774 and act investing in the future of our health were conducting this hearing remotely using the Microsoft teams platform along with committee members and staff participants in today's hearing include those elected officials and other members of the public who pre registered to testify. This hearing is also being streamed live on the legislature's website. A legislature dot gov. An archive video of today's hearing will be made available on the site within a few days for those watching on the livestream, any individual or organization may submit written testimony and supplemental information on any of the bills on the docket to the committee via email. Those submissions should be made to the House and Senate chairs as well as the committee director via the email address on the public hearing notice. And perhaps we can ask one of the staff to put that in the in the chat. We're going to hear testimony from elected officials and members of the public who registered by the four p.m. friday april 8th deadline, elected officials will be taken out of turn as is the tradition of the committee. Persons wishing to be recorded on this matter that are not testifying today should send written testimony to the committee. Mhm. So during today's hearing, the chat function is reserved for the use of committee members and staff only. So if you have the public please don't put a question in there because we won't see it for those who are here to testify. When I recognize you to speak. Please240 on mute your audio and state your name the subject. Well we're hearing one bill today so we know what you're going to be talking about and then begin your remarks. Individual testify Ayers will have three minutes to speak except in the case of panels of three or more persons. In that case you will have nine minutes for the entire panel. The chairs at their discretion may further extend or limit the time for testimony. Committee staff will keep time and using the chat function, notify speakers when they have one minute remaining on their time and then 30 seconds when an individual or panel276 has concluded their testimony. Please remember to a mute your microphones during the testimony. Members who wish to ask questions should ask to be recognized by using the chat function. Just type I have a question. You don't need to tell us what it is. Please do not in fact type your question in the Czech, I will call on committee members who have questions after an individual or panel has completed testimony. The order of questioning will be the presiding chair, the co chair and then any members that have asked to be recognized. All members again are reminded311 to remain muted until recognized by the presiding chair. Members who ask a question. Please keep your keep a muted during the response. So we can allow for follow up questions when finished. The member who has asked the question should just let me know by saying I have no330 further questions. Um and then if there are none of I will call the next individual and participants, anyone is free to log338 off the team program at the conclusion of their testimony. Okay, so moving on, we are now starting welcome everybody. I'd like to um stands a warm welcome to his Excellency the governor um to the Secretary of Health and human Services and to the under Secretary of Health policy for um excuse me um at the Executive Office of Health and Human Services. Hello governor, I just lost you.
How are you? It's nice to see you. It's nice to see all of you to tell you the truth in a manner of speaking. We were hoping to have this in person, but here we are and it's good to see you.
GOVERNOR BAKER - SB 2774 - So first of all I just want to thank you chair Friedman and chair Lawn and all of the members of the committee for the opportunity to join you today and I especially appreciate the fact that um we're testifying on behalf of the bill that we filed last month, an act investing in the future of our health. I think many of you will recall that I last testified on health care legislation before this committee in January of 2020. We had a very positive exchange of ideas and then, as I'm sure you all know a few weeks later, everything changed. And since that time we've been working together to guide our state through this pandemic. I want to thank you for your collaboration and enacting several of the key provisions that we filed in that 2019 legislation and implemented on an emergency basis through executive action during the course of the pandemic.
And in particular, I want to reference the telehealth coverage and the expanded scope of practice for nurse practitioners and other specialty nurses. Those have made a big difference with respect to people's ability to access a variety of health care services here in450 Massachusetts. The pandemic demonstrated the incredible resilience of our health care workers and demonstrated why Massachusetts continues to be a national leader in health care. But Covid also shone a spotlight on some underlying challenges that we continue to face. In particular access to behavioral health care and other services that keep people healthy over time. This is the core elements of the legislation that is before you today,475 an act investing in the future of our health builds on prior reforms and lessons learned during the pandemic.
It also renews several proposals from our 2019 bill. Most notably our proposal to systemically reform the way healthcare prioritizes and invest in primary care and behavioral health. 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 definitely cured disease enhanced therapies and saved lives. But as that focus and the successes achieved has dominated what and how we pay for health care we failed to appreciate the changing nature of illness and the systemic gaps and care delivery that have been created by this approach. Well, many people would argue that524 the fundamental problems with the healthcare system are rooted in some provider organisations being paid too much and others being paid too little.532
I would argue that 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, Simply put the care delivery and financing system we have today that was built on the Medicare fee schedule which was developed 50 years ago is not designed to take care of the people and the patient's we've become and our health care needs in the future. We pay for a system that's built on transactions and technological advances, not on collaborative care delivery, therapeutic support or a combination of both.
And while technological technological advances remain a critical component of delivering effective healthcare, the 21st century healthcare system should presume the 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 the population based health management requires time and connection. Solving this problem at the state level is complicated by the overreaching role played by public and private payers at the national level across this country and for the most part, national payers, including Medicare, which is the big dog in all of this uses payment policies that favour technology and transactional medicine at the expense of primary care, mental and behavioral health and addiction services and, ironically, geriatrics.
Almost all providers and payers 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 we are here to support today is designed to create positive financial incentives for healthcare 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 healthcare providers invest in these services which are underfunded by today's payment models and to incorporate these services more directly into their care delivery strategies.
Specifically, our proposal sets a target of 30% growth in these areas over the next three681 years, while requiring that overall health care spending remained 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. For example, on paper, that would mean that a payer that spent $100 million on these services in the aggregate in 2019 would need to increase that spend to $130 million by the end of705 2024. And overall, this proposal would add an708 additional investment in primary and behavioral health care of about $1.4 billion over the course of the next three years.
But what does that math equation mean for the residents of the commonwealth who are tired of waiting 6723 to 12 months to see a primary care physician who often pay out of pocket if they are able to find a behavioral health specialists who will see them or who have no other avenue but a trip to the emergency department to access mental health care? It means that our health care system would be moving in a direction to support and engage these folks differently to achieve this target. Insurers will be invented to increase their rates of reimbursement for behavioral health care and expand their networks. In turn, their members should have access to more755 in-network providers and services so they're not left paying out of pocket privately or resorting to the emergency room for treatment.
Provider organizations will be incented to764 expand telehealth capacity and increase access to their practice sites through extended evening and weekend hours, which would mean 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 be used to fund to provide the fund will be used to provide enhanced funding through mass health rates to group practices, community mental health clinics, substance use disorder, outpatient providers and other primary care and behavioral health providers serving Medicaid members.
Approximately 20% of the funds will be earmarked for806 targeted grant funded initiatives and equity communities around cancer screening clinics, improving language and disability access among ambulatory settings, inpatient and community education on the destigmatization and availability of mental health and substance use disorder 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 that are brought to light throughout the course of the pandemic. The legislation also includes several other reforms to promote behavioral health parody a goal I know we all share to ensure behavioral health is treated the844 same way it treats physical health, including 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 ensures reimburse certain mental health clinicians and training, which is consistent with policies that Mass health already has in place.
These proposals doubled down on our commitment to behavioral health reform and complement the work that's underway to implement the behavioral health roadmap, which outlines tangible ways we can increase access to these services. For example, our fiscal '23 budget includes $115 million to implement that plan, including funding for a new centralised and staff behavioral health helpline available 24/7 as of next January to provide life support, clinical assessment and connection to the right mental health and addiction treatment in real time. It also would readily make available outpatient evaluation and treatment through primary care, supported by new reimbursement incentives as well as same day evaluation and referral referral to treatment at designated community behavioral health centers throughout the commonwealth.
These designated behavioral health centers will be announced in June of '22 come online in January of '23 and it would truly provide 24/7 mobile crisis services. The reforms were filing today would build on this work and further promote increased access to behavioral health services in primary care. The reforms are systemic designed to address the underlying challenges the system faces as we continue to work together to improve access to behavioral health and other critical services that our residents need. We know that our partners in the legislature agree about the need to promote access to behavioral health care services, especially in light of the impact of the pandemic and what's that done what the impact that's had on people generally.
And we believe that this bill represents an opportunity to make fundamental changes that can make this happen. We've taken bold action before to make transformational improvements in our health care system and the care that is provided to our residents. And we look forward to working with you to make that happen once again during this legislative session. And I want to turn the platform over981 to Secretary Sudders so she can talk a little bit about some other aspects of the bill, including changes to control prescription drug prices for residents and families. And again, I thank you for scheduling this hearing so quickly after we filed the bill and we look forward to working with you to get something done by the end of the session.
SECRETARY SUDDERS - HHS - SB 2774 - Good afternoon madam Chair, Mr. Chairman and other members of the joint committee. at the outset I also want to formally take a moment to thank your staff, the staff of your respective ways and means chairs and the staff of the speaker and the Senate President for their time and attention to this bill. The three pillars of this legislation are prioritizing1022 primary care and behavioral health managing specific health care cost drivers and improving access to high quality coordinated care. Continuing from the governor's testimony TThis legislation directly addresses rising health care costs for employers and individuals, including important consumer protections regarding managing healthcare cost drivers.
As all of you know, I don't read all my testimony. So the first, specifically, we seek to one hold high cost1052 drug manufacturers accountable by leveraging the existing statutory framework that is currently used for payers and providers that exceed the comparable cost benchmark. Two penalize manufacturers for excessive drug price increases. Three regulate the middlemen known as pharmacy benefit managers, or PBMs that we know add to drug costs, and four require that PBMs use a single maximum allowable cost called the MAC that would prohibit spread pricing practices. Second too often, so that's under drugs on consumer protections we hear stories about surprise medical bills and other unforeseen medical costs borne by the consumer.
This legislation not only1104 prohibits facility fees, which are a source of unexpected cost to the consumer, but also establishes a default payment rate of reimbursement that carriers must pay to out of network providers for unseen, out of network services. This will protect consumers from unseen, unforeseen medical bills, while also ensuring providers are adequately compensated. Most importantly, it takes us the consumers out of the middle of a dispute between a health care provider and payer and some of the areas around improving access to high quality coordinated care. So around small businesses, we know that small employers experience higher year over year premium growth than other market segments.
We recognize that health insurance costs are increasingly a burden on small businesses and their employees. So we propose several reforms to ensure small employers and their workers have access. These proposed reforms are drawn from the work of the merged Market Advisory Council that we create in 2019 which recently issued its report. Then on scope and workforce as part of the effort to remedy a critical shortage in the health care workforce. This bill modernizes licensure and scope of practice standards for certain healthcare1189 professionals that allow providers to practice at the top of their license and remove barriers to licensure, bringing Massachusetts in line with the majority of other states.
The bill improves access to telemedicine by allowing providers to render telehealth services without limitation to location or setting, and authorizes entry into a multistate physician licensure compact and with regard to urgent care. This legislation also establishes a1222 framework and regulatory structure for urgent care services. There is no clear definition of urgent care services which has led to patient confusion and variation in oversight and finally, data. This legislation establishes clearly defined data standards and processes for sharing of healthcare data that's important for both population health, care coordination and overall patient centered care. Uniform data standards support efforts to address health disparities, which starts with data collection.
We can't collect data in a standardized way, it is very difficult to measure it and last if there is one key takeaway from our testimony, It is this Senate bill 2774 is systemic reform. Together, we have had the courage to take bold steps to improve health care for our residents. This is a step that will change the way we as a commonwealth prioritize healthcare and increase access. As always thank you for your time and attention and we look forward to working with you and your questions. SHOW NON-ESSENTIAL DIALOGUE
Great, well, thank you both. Um,
thank you for the overview. Um, it's good to see that, um,1310 even though we don't always make it to the finish line, good ideas stick around and uh, you know, there's a lot of things in this bill that certainly I can speak for the Senate to say. Um, yep, we agree. Um, we've got a number of bills out there that really does nicely with what you presented with us.
SEN FRIEDMAN - So I'm going to ask two questions and then open it up. There's a gazillion questions to1339 ask as always, but I want to be respectful of the other members. So the first question that I have is, and this is a little convoluted. So I'm going to try and be straight as clear as I can, the 30% increase um, is by the way, something that I wholeheartedly support. We'll tell you that out of the box. What we have seen, however, is in our cost growth benchmarks and the trending of healthcare We keep seeing it go up and up and up the costs are risinG. The costs are rising for consumers Um in a way that is frankly quite alarming. So the question that I'm trying to get at, the thing I'm trying to understand1391 is we do have this benchmark and it's just a benchmark, right?
It's saying let's everybody try and keep within this limit, but we're not really doing a great job of it. And it's things like Mass health coming in, you know, with a 3% reduction in costs that helped the whole system kind of move to the benchmark. So what do we need to do and what is in this bill that will really tell us and and make the system accountable for the for the movement of care from let's say specialty to primary and behavioral health versus the system moving money around where what's happening is we're just spending more money or those who already have the money can put more money into the system for primary care but we're not really shifting money. You see, we're not... you see what I'm asking?
We're not really keeping it capped. We're just finding different ways to increase the dollar amount. I'm really concerned about this and I'm not sure that we are doing a great job and this is not this is not a criticism. This is a we spent 10 years trying to, you know, 10 years with a wonderful system. We've learned a lot. How do we fix it so that we really are getting at the cost increase. Does that make sense?
BAKER - Well, yeah, on a couple of levels and let me just start with this and then the secretary can give you a more educated answer than mine. Um the first of all, I think the last couple of years with Covid just really makes it complicated to figure out what actually is going on and how this all worked and it had huge consequences just across the board in so many ways. But um, you know, I used to run a health plan once upon a time and the way the conversation would take place between us and um, and the folks we worked with on the provider side was some version of and it still is today. Um we would like to negotiate a differential way of paying for primary care and specialty services with your organization so that you um will invest more money in those areas because we believe that if you invest more money in those areas overall, we will spend less.
And the problem I always ran into is everybody basically1563 said, look, we pay everybody on the percent of premium or percent of Medicare and it's right off the fee schedule. And if the Medicare fee schedule doesn't provide a significant amount of support for those services, it's very hard to get folks on the provider side to do anything other than fund them the same way they fund everybody else. That's how people defined equity across a group. So if everybody in the group is going to get paid 150% of Medicare or you know, 75% of Medicare, whatever it might be that's going to be the way their fee schedule is going to work. That's going to be the way they think about how they invest in their practice and that's going to be the way services get delivered.
And the consequence of that is over 50 years we just invest less and less and less proportionally in primary care, addiction services, geriatrics, which I think is very interesting and and behavioral health services overall. And if we've learned1623 anything from the past 20 or 30 years, those heavy investments that we've made in technology and what I think of as transactional services have saved a lot of lives. I mean, there's an enormous amount of progress that's been made in helping people recover from all kinds of acute incidents and episodes. But what that means is that we have a lot more people who are dealing with chronic conditions in many cases more than one.
And we don't, we do not invest proportionally in the collaborative approaches to care delivery or the primary care of the geriatrics or the or the time spent with a patient that's dealing with three or four different issues that we need to. And the only way that's going to happen, the only way that's going to happen is if we get out from under running this system on that Medicare fee schedule platform, because the longer we stay there and don't do anything to change it, we're going to continue to make the same kinds of investments proportionally in the delivery system that we've always made and I don't think those are necessarily the right ones. If you want to provide complex patients with1692 a more collaborative approach to care delivery that often involves behavioral issues and other forms of what I think of is um sort of time based care delivery.
And um and I'll tell you something else, I actually believe that if we, if we made these investments, we would spend less in a whole bunch of other areas. Not because we cut their fees, but because people who currently see 20, 30, 40, 50 clinicians a year because they never have enough time to spend on their behavioral health issues, their addiction issues or their their primary health issues, they spend more time with those folks, less time pinging all over the system. And honestly they get better care, which1737 is at the end of the day, what we're supposed to be doing. I think part of our problem is is really rooted in and the fact that that1744 fee schedule just doesn't make sense in the 21st century for patients or I would argue for care delivery generally. And it makes the system less effective as a care delivery system and a lot more expensive.
SEC SUDDERS - May I just to add to what the governor said madam chair. So just and I know, you know these numbers, so just building on the history. So today, so this is 2019 massachusetts spends 15.3% of all medical spending in primary care and behavioral health. So if we1779 don't do some kind of course correction, we're just going to continue not investing in primary and behavioral health care and the drug proposal and I know the Senate also has1791 a bill around the drug pricing. I think if we actually bring the drug pricing within the framework, the statutory framework and really shine a light on drug pricing, I think that will um start to create opportunities around how one invests in in primary care and behavioral health care and what this bill at the heart is and it wasn't a convoluted question.
It was great to hear you support the the 30% is that what does mean is that you invest more for a period of time in primary and behavioral health care and hold other things to less of a growth. So it's not about cutting services, it is about prioritising what you're going to invest in and what we're saying is it is time to invest in primary1840 and behavioral health care in order to open up access, give some tools around managing drug costs and the PBMs and the like and this drug, the drug spreading that we think will actually start to create some opportunities for us.
FRIEDMAN - Okay, so you so what I'm hearing you say is that there's the pieces of this bill, for instance that address the pharmaceutical cost increases will be the money that we can look at and use to shift the dollars. Because I am, I mean, I1879 believe this lock stock and barrel, it's what we should be doing, not just for the cost but for the quality. And it's and I agree with you that we need to like do it. I just want to make sure. Go ahead.
SUDDERS - And also together we're stating that in this commonwealth at this time and certainly the lessons from1904 this pandemic is that we have to invest and open up access to primary and behavioral health care that is our joint commitment to residents of the commonwealth. So it's as much about making that statement and then using the statutory frameworks that the legislature has created to bring all that together.
FRIEDMAN - Sure. Yes. And that makes sense to me and I think one of the things that we're going to be looking at is where in this bill, how do we get to those dollars that are going in one place now and really need1942 to go into another without increasing the total cost of health care and I think that's the concern. And so and that's what my question was trying to get to, but I, you know, I thank you for putting it in, I thank you for putting it in last time and um you know, I think this is something that we all need to take a very, very serious look at. So second question.
BAKER - Can I just add one more, just add one more point to the to this,1974 because this part of the discussion is really important. Um If we were proactively putting more resources into expanding and improving the comprehensiveness of our primary care and behavioral health delivery system, we would have a lot fewer people in the ER with no place to go and that is by far the most inappropriate and expensive way to provide care to a lot of the folks who make up the population we're talking about here. And there is definitely something to the idea that in this day and age, um particularly when it comes to dealing with some of the issues2016 around addiction and behavioral health care.
If you can keep people healthy, if you can provide them with a constant ongoing source of support as they deal with their issues, they are much less likely to end up um in2032 what I would describe as the downward spiral that most of the time is not really organized to support them, doesn't do a very good job of helping them get back on their feet and we simply don't have um an approach to dealing with that other than um the court of last resort, which in this case is the ER which is enormously expensive and um and it's not it's not the right answer for them in the first place.
FRIEDMAN - I absolutely agree. And and our our job or our problem to figure out is how do we get all of the stakeholders who have a system in place that's working for them? How do we make that shift so that it goes to the places where we know all the data tells us. That if you really want to take care of people, you take them in the primary care space and along with social determinants of health and you give them really good care and that's how you mitigate a lot of the issues that we're seeing. So we we are on the same page and the question is how do we shift that system, you know, that that huge, huge tanker around so that we start to do the right thing. So thank you. I think I'll hold my question because I see there's so many others um Mr Chair, do you want to ask a question?
REP LAWN - Sure and just a brief comment, thank you Governor Baker and Secretary Sudders for your tremendous leadership through the last two years of the pandemic when this bill, I think as the governor mentioned briefly was heard on January 28th of 2020 we had no idea what lied ahead of us, especially, you know, the entire world was going to deal with something that we had no idea was coming ahead. Um, so I appreciate all of your leadership and I have one question regarding like two years ago, during that hearing, we had a workforce challenge and today that challenge has2161 just gotten wider and wider and our biggest challenge in the primary care and behavioral health space is the pressing need to increase our workforce.
How does it help us to demand such a large increase in spending in both of these two areas if we still do not have enough providers to really expand patient access to care? Can we provide the supply, can we provide the supply of providers to meet the increasing demand we will create in these next2192 three years?
BAKER - That's a really good question, I'd say a couple of things and then I'll turn over the secretary. The first is um, several of the reforms were proposing are designed to make it more likely than a number of folks in the behavioral health space will be willing to be in network providers instead of out of network providers. Part of the reason um, Massachusetts has, I think we're certainly in the top five.2223 There was a time, not too long ago when we were number one in the country in terms of the number of practicing behavioral health therapies at every level that we had operating in Massachusetts, but the reason it felt to so many people in Massachusetts, like we didn't have a lot of capacity at all is almost all of it was, um, not almost all of it, a big chunk of it was not participating for a variety of very good reasons, um, in the, in the commercial insurance marketplace.
And um, and actually you fixed some of those issues with the legislation that we signed about a year ago. And I think part of this is about getting rid of some of the there is literally2266 administrative infrastructure here that is designed to make it difficult for um, for more folks to participate who are clinicians in the insured side of the health care system. And I think part of what we're trying to do here, in addition to many of the other issues around behavioral health is to make it easier and to level the playing field to some extent between the way behavioral health gets treated and the way other services get treated when it comes to insurance, which would certainly make more services available on an in network basis, which all by itself would enhance the access that many people currently don't have.
SUDDERS - So Mr Chairman, just to add to what the governor said, I think that there are some specific things in this bill, as well as what the Legislature recently appropriated in the ARPA bill that addresses some of the workforce2319 challenges. So, first by saying is the commonwealth that at this time we want to invest in primary and behavioral health care. We're sending a message to people that not only are we investing in services, but we're investing in the people who work in these fields. And I say that as a social worker that we are, we are we want to whether it's increasing rates, taking off administrative burden and the like that we want to invest in you to work in this space. So we're saying right,2351 we're signalling that behavioral health and primary care are places where we want people to work.
We take on some very specific arcane issues quite frankly in the behavioral health space. We need trainees and behavioral health, but only in Mass health will we allow trainees the provider to build for the trainees clinical time and just imagine you run a mental health center, a mental health programme and you want to have trainees, but you can't afford to have the trainees because they are not going to be able to be reimbursed and add to your revenues. So we take on some of the arcane and I know the legislature has also taken on some of those issues. So we try to take off some of the administrative burdens as well and we say though, as a state, this is a place we want you to work in, we want you to be in behavioral health, we want you in primary care and that is part of like investing in the services and like.
In addition, we have a number of things in here about scope of practice and belonging to the physician compacts that most other states do as a way to increase the workforce. So we try to take off some barriers around access why people may not want to work in the2431 behavioral health and primary care space. We value the services that they're providing and then we add some very specific items around expanding, expanding the workforce by enjoining some of the compacts and like. I'll just give you one reason why the compacts are important for our military families. If a military family is is transferred from one state to Massachusetts and their spouse is a physician, for example, there they, if they belong to the compact, they would be able to practice in Massachusetts rather than2465 have to go through the onerous licensing process. So these are just some things. Again, these are parts of the strategy to invest in workforce in Massachusetts. I wish there was one simple answer sir.
BAKER - I do, I will repeat though. I think it's important that we do believe we under invest in both primary care and behavioral health services and if you under invest in something you generally get shortages. I mean that's kind of economics 101. And if we commit to spend a billion for an additional resources on these services over the course of the next three years and everybody knows we're doing that. It will have an impact on both who chooses to get into the space and who chooses to stay. I mean one of the other problems we have is a lot of the folks um don't stay and they don't stay because they get into it and they realize that this is just not an area that historically we or any other state because everybody uses that Medicare fee schedule um chooses to uh chooses to invest in and2529 they do something else um or they go purely private and take just take just take private pay.
Then there's also a lot of healthcare folks who are in the Hire Now.2543 The Hire Now program that we just announced which several members of the legislature came to the announcement on that. There are a lot of folks in the health care world who have signed up to to train bonus and um2557 and support new hires that they're planning to bring in to fill gaps they have in their in their workforce currently, which is also a good thing and a demonstration that health care is one of the areas where um there's definitely an interest in trying to find ways to bring people in and keep them. SHOW NON-ESSENTIAL DIALOGUE
great all set mr Chair, yep. Thank you, rep Livingstone Livingstone Sorry, thank you.2582
REP LIVINGSTONE - Thank you Governor Baker and thank you Commander Sudders first of all for what you've done the last two years regarding the pandemic and2596 keeping our health care system afloat, and but then also continuing to advocate for improvements to our healthcare system. I wanted to follow up on some of the questions or the question that chair Friedman had to make sure I understood. With respect to that increase in costs putting being put on increased spending requirements regarding primary2621 care and behavioral health, if if I understand what you're saying is first kind of intuitively, if there's more preventative care, there2632 should be less care needed overall, including less emergency care.
And um sometimes that argument works out some but intuitively makes sense, but it doesn't always work out as you expected to. And then you also have a piece to potentially lower drug prices, outside of of that argument and the proposal, the specific proposal for drug prices, are there any other mechanisms for controlling costs that you're proposing on this bill? And the reason I ask is we hear about the trouble getting appointments to behavioral health appointments and and the lack of resources for primary care. We also hear um that premium costs are too high in Massachusetts. And that uh if you talk to some people in the legislation, we propose actually drives up premium costs. And so I wanted to get at what what what do you if anything are you proposing to control cost. Thank you.
BAKER - I guess, you know, not to sort of over overuse analogy, the if you're not spending your money on the right things, you're going to end up with a more expensive system. So if you're not spending money on geriatrics, and you're not spending money on behavioral health and you're not spending money on addiction services and you're not spending money on primary care, you will get a more expensive system and that's pretty much what we do, and we've been doing it for a long time, and I would argue that um I wouldn't call the system upside down, but I would call it misguided in some respects when you look at the nature of illness as it exists today, where you have more and more people managing chronic conditions in many cases multiple chronic conditions than you had a decade ago or2755 20 years ago.
And there is very little about the way the system2759 is organized that's changed to reflect that, and the reason the system hasn't changed it's because as I said, the whole thing runs off a Medicare program, it developed a fee schedule in the 1960s and has done very little to adjust the way it operates since then. And if you have a system that is driven by investments in technology, you are going to get a more expensive system. If you have a system that doesn't invest and the kinds of services that are most likely to keep people from getting really sick, which is kind of what we have, you are going to get a more expensive system. And I would argue2794 that these changes that we're proposing, which would be dramatic relative to the way the system operates pretty much anywhere else in the country would have real positive consequences on both care delivery, patient satisfaction and cost.
Um, but if we just sort of tinker around the margins and say we want a little less of this or a little more of that and don't go hard at the things that we've been under-investing and for a really long time, we are unlikely to get the change in the cost curve and in patient satisfaction that you guys are talking about.
SUDDERS - So to be a little bit concrete, um, facility fees, the farmer reforms emerge market reforms that would provide individuals and small businesses with more affordable coverage are all real cost savings to the commonwealth of Massachusetts and to consumers. SHOW NON-ESSENTIAL DIALOGUE
Thank you.
Great to go into details with the staff of course, and you and the details of that cost savings.
REP LAWN - Actually, I have one more question chair regarding the governor you're making a very passionate point and, and2873 I know you've thought about these issues a lot based on your experience before being governor and then as governor. Has, has anyone modelled this? Is are there any studies out that that this proposal would be, would come out the way that you hope it would? Um, I'm not saying that what you're saying doesn't make sense. I'm just, I want to get at at the basis. Thank you.
BAKER - The single best example I can give you is um, if you take some of the European2908 countries that don't have caps on their budgets, right? But have2914 operating models that and financing models that are very different than ours. The single biggest difference between their models and our models is they spend a lot more money by design on primary care and behavioral health. And as a result, they don't get what we often see which is so many people struggling to manage their way through complex medical conditions and literally just getting tossed from one one provider, one organization,2943 one specialist, one medication to another. And the2946 other thing they've done in a number of cases better than us is they've done a much better job of managing um pharmaceutical use for their seniors.
So that, you know, in the US you have a lot of people over the age of 65 which I now am um who have multiple medical conditions that they are chronic and um and they take a variety of medications and um if2973 you're spending 50 if all of your providers, 50% of all of your providers are primary care providers, you have tremendous access to primary2982 care and those folks spend a lot of time with their complex2986 patients, making sure that the medications are on the right ones. That the the um that some of the issues associated with taking certain kinds of medications at the same time get addressed and get addressed quickly and they end up spending a lot less money than we do as a percent of their economy overall and health care. Those are the, from my point of view, those are probably the best examples.
BAKER - The two things I would just add to what the governor said is and though it's not apples to apples, Rhode Island had put in place a requirement to increase spending in primary care for a couple of years is very, very, very modest increased just in primary care. And secondly, I would just go back to the fact that Massachusetts sets the stage often on healthcare. Um you know, we led the country on insurance coverage. We have led the country on attempting to wrangell, wrangell costs. So I would just, I would on occasion we need to sort of take that leap together and understanding then we continue to need to monitor and measure and then take corrective action if you need to, so both, but we really would be leading the pack here in terms of state3069 action. SHOW NON-ESSENTIAL DIALOGUE
Thank you.
Thank you. Um rep Livingstone rep Kane
REP KANE - Thank you Chair Friedman and thank you Governor Baker and secretary for being here today and really thank you for your commitment not just for the last two years to addressing the issues during the pandemic, but really your seven years of leadership in the healthcare space. The question that I have is really one of how do we3101 ensure that if these investments are made they're going to be done in a way that is um sort of equitable across the board. Um so that access is occurring for3112 all and and everyone is seeing access to those investments.3115 And I raised this um, you know, sort of two different hats. One being a member of the women's caucus this year as you know, governor from our meeting with you, you know, health access and racial disparities as one of our strategic priorities and making sure that we are addressing that in the health care system.
Um and then also as our committee, a member of the Committee on Racial Equity and Civil Rights and Inclusion again, you know, really focused on ensuring that the work that we're doing as a legislature is addressing access and equity. So if you could just speak to this bill um3149 and these investments and what they're will ensure that as3153 they are being made, they are being made uh all across the commonwealth um and access um is occurring for all.
SUDDERS - So one of the things in this bill is that that we built in was out of the pharmacy reforms is that the penalty for um excessive pricing of drugs would go into a equity trust fund and that would do two things. Um One is because we know the disparities and we know the lack of, as you would say, the consistency of standards would do a couple of things.3192 One is would in fact increase rates uh to address disparities and secondly also to invest in some of the practices and uh providers that did not did not receive funds from either the covid relief for the ARPA funds to really address some of the we've tried to attend to some of the needs of hospitals and community health centers and others, but there are other providers within equity communities that did not have access to some of the ARPA and Covid relief funds.
So one was what we create a trust fund, an equity trust fund was very important as a way to bring funds together to invest in those communities andin those services to address disparities. And secondly, we use the same the same framework that we use for for providers and payers to really then set the baseline for what the spending is on primary and behavioral health care with CHIA and then measure it over time to see in fact is are the investments being made in primary behavioral health care. There is a three step process where CHIA would actually establish the baseline and what the costs are for behavioral health and primary care. And of course we would do it in a very transparent way And let me be clear when we say primary care It also includes maternal health in that.3276
I think sometimes people think that primary care is just like the visit to your primary care physician but primary care in this definition includes maternal3284 health, which you know3286 has great disparities in that, right. So you create the baseline and then you measure it over the course of3293 several years and that's the only way we're going to know how we measure progress. The other thing Representative Kane and it really came up um I remember the press conference early in in the pandemic where we ordered if you recall um uh that providers and payers had to provide race and ethnicity data and3319 it was one of those sort of stunning moments that you actually had to remind people. You can't report data if it's not collected and one of the provisions in this bill is to have uniform data collection and definitions to ensure that in fact like race and ethnicity data is collected across payers and providers in a very uniform basis.
If we really I know that sounds maybe a little wonky to people but if we don't define and collect the data uniformly and then provide the data publicly it's very difficult to measure both the disparities and progress and that's another provision in this bill. SHOW NON-ESSENTIAL DIALOGUE
Thank you secretary.
BAKER - I would argue that data, that data definition and uniform collection policy is a really big deal. Um not just in health care, there's a lot of areas where we should be doing more of that. SHOW NON-ESSENTIAL DIALOGUE
jerry Friedman I just had one follow up question if I may.
KANE - Um the other question I have is relative to the PBMs and um what do we know about their role in health care costs that brought us to the point of what you have in your legislation here today. Sort of what's it based on and I don't disagree with it. I'm just you know, what's the basis for putting it in here?
BAKER - I think um I'll give you the I'll give3410 you the uninformed answer and you can get the informed one from the secretary. The uninformed answer for me is I have spent several years watching the manufacturers, the PBMs and the pharmacies all argue it's the other, the other's fault that the costs of prescription drugs are so high. Um It's hard to answer a question about what's actually driving the cost of prescription drugs if you don't have access in some way to the information associated with this whole supply chain. And I would just like to end this discussion, this debate, this unknown, whatever you want to call it once and for all3462 and do the data collection and get the information and figure out what's actually going on there because they all blame each other for the rising costs of prescription drugs.
And I, you know, I don't know how else to solve this other than to3478 say they all got a report and they all got to um contribute their data and their information and make it possible for people to understand what's really going on inside the supply chain.
SUDDERS - So there's two things. One is that we were we would require PBMs to be regulated in the commonwealth. So that's first and foremost As the governor said,3498 it is the only way to resolve some of this um underlying debate if you would is to like raise the hood. So one is we call for regulating PBMs and then second is to restrict spread pricing and spread pricing is two things. So one is what the PBM um reimburses the pharmacy uh is different than what then the PBM charges the payer and then there's also PBMs reimburse differently independent pharmacies and large pharmacies, chain pharmacies. So the idea is if we regulate excuse me and eliminate and require basically the use of one, what's called one MAC that you will act, we will save um a fair amount of money uh in doing that and um just level the playing field. So those are really the two things in this bill is one regulate and secondly, basically restrict spread pricing. SHOW NON-ESSENTIAL DIALOGUE
Thank you.
Thank you, rep Sabadosa
REP SABADOSA - Thank you very much Chair Friedman. Good afternoon Governor and secretary.3577 It's a pleasure to be here with you today. I really appreciate how this bill delves into the realm of behavioral health and I wanted to ask a question about Section 21 and Section 52 of the bill, which talks about the board of registration for peer workers. Um I have many organizations in my district that use peer workers that's something that I really believe in and I I guess I'm a little curious as to how, as to the genesis of these sections of the bill and how secretary you had mentioned that the goal is really to remove barriers to access, how you view these sections as removing barriers to access.
SUDDERS - Well, thank you for that. We we share in and wanting to expand the peer workforce throughout health care and not just mass health. So by creating a certification process of all of our peers, right. We have recovery coaches. We have um behavioral health peers and like specialties is to really create the path forward to be3649 covered by all insurers and not just Mass health. So really expanding again, it's like the I'm trying to find the word because it's not legitimizing, but it is...
BAKER - No, it is credentialing.
SUDDERS - It is credentialing the and by credentialing saying the peer workforce is important to the delivery of health care in the commonwealth at all levels in the commonwealth and should be certified then and credentialed in order to be reimbursed by all insurers and not just the Medicaid program. So we're really trying to expand. Sorry, Governor really trying to... thank you.
BAKER - I'm kind of excited about this one too. So yeah.
SUDDERS - So that is really what this is to do, is to create the umbrella certification process to expand peers throughout the commonwealth, all levels of health care, emergency rooms, forensic, inpatient, outpatient um, and then insurance coverage. I'm sorry governor.
BAKER - I was just going to say that, you know, we had the we had a very similar discussion and I totally get your point about, you know, setting up a certification program looks like just the opposite of opening the door. But what I would say is we had a big debate and discussion about recovery coaches um for 5, pandemic screwed up all my dates maybe six or seven years ago. And um and part3742 of the argument about that was um there are a lot of people who are just claiming to be recovery coaches and we therefore, the insurance industry aren't going to pay for them and we the um the health care providers aren't going to bring them onto our team and engage them unless we know they've been credentialed in some way.
Um when we created a credentialing program for recovery coaches, it actually did the opposite, it opened the door. It opened up the door too far more places and spaces in which they could3774 practice and get paid and um and it had a huge impact um before the pandemic on um on a number of things, including the number of people who were getting recovery coached into treatment who were chronic arrivals at the ER for overdose issues. And I think the credentialing, you can do credentialing well and you can do it badly. Okay. Um there's no question about that, but I do think if and I am a huge fan of peer providers, I would like to see a lot more3815 of them. I think part of the way we get3818 a lot more of them is we create a credentialing program.3820
We give them a reasonable process through which they get credentialed and and then they become part of what I would call this. That's a great example of an expansion of the primary care and behavioral health system, which I think we all would like to see more of. SHOW NON-ESSENTIAL DIALOGUE
Thank you very much.
FRIEDMAN - Great, thank you. Um I don't see any other questions. So I would like to ask my last my question last question and that is um it's almost the end of April um there's an enormous number of things on the plate of the Legislature. Um This bill has really important things in it3866 that I know that we care very, very much about both the legislature and the and the executive branch. If we if we are limited in what we are able to do you are there things in this bill that you believe have are of such high priority that you would say we've got to do this? Is there are there is there a way that you can help us navigate through this pretty complex bill that um again, has really important things on it but are there things in it that you think are going to really change the direction that we're moving in in terms of providing high quality um access and affordability for the residents of the commonwealth? And that may or may not be a3930 fair question because when I put things in a bill, there are all things I really care about but I'm just, we're looking3936 for um, your thoughts on this.
BAKER - So I'll pick one and I'll let the secretary pick one. I mean, obviously I care deeply about flipping the paradigm on the fee schedule, because I think if you don't flip the paradigm on the fee schedule, honestly, I really do believe we'll never, we'll never get at the underlying problem that we have.3960 Um, and, and for me, that means, um, using state statutes to get people off this historical, traditional and um, almost ritualistic reliance on the Medicare fee schedule to determine how we prioritise what we think is important in health care. And3986 I do believe that if we don't do that, there's3990 not a lot else that's going to get us to where we need to go, because that fee schedule is just baked into it's like baked into the marrow of everything that goes on in health care generally.
And um, if you want, if you want, if you want medical schools, if you want medical students, if you want graduate students, if you want, um, care providers, if you want, if you want people to make a significant investment in behavioral health, primary care, geriatrics and addiction services you have to do something about the way the Medicare fee schedule works or you can't get there. So for me that would be the the most important element in this from my point of view, it's probably the hardest implement to which I apologize for.
FRIEDMAN - Does it make it not worth it?
BAKER - Absolutely.
SUDDERS - I'm sure we'll be working with um the Legislature on on health care and behavioral health. I completely agree with the governor that this is the time to invest in primary and behavioral health care. Um and really make that statement strong to the4065 citizens of the commonwealth. I do think I can't just pick one usually I can, but I can't um I do think the the pharmacy package is very important. Um, if you want to, if we want to um reduce costs4083 and increase consumer protections and there's really some ones in here that like the surprise billing are ones that, I mean,4093 I can personally attest to having to manage him almost $10,000 in surprise billing and my sister last hospitalization before she died.
And as some people have said I was sublimating my grief and it was, but the fact that I had to spend hours getting rid of $10,000 in surprise billing no consumers should have to face those kind of things and those are strong consumer protections. So I ask you to look at the consumer protection pieces of this, the pharmacy pieces of this and really being bold on expanding primary and behavioral health care. SHOW NON-ESSENTIAL DIALOGUE
Thank you. I really appreciate you both answering that question because it's not, again, it's not like something doesn't matter, it's just figuring out what matters four. So I appreciate that chair Lawn Do you have any final questions?
LAWN - Sure. Just I know that the over the three year period looking at an increase of I think you said $1.4 billion um could you just provide some additional clarity on how you would define primary care and behavioral health for the purpose of the proposed benchmark in the spending target?
BAKER - How about if we um how about if we just deliver that in writing to you and to your um committee staff so that um it's just all in one place and you can send it to everybody else. Would that work? Okay.
LAWN - Yeah, thank you, governor.
BAKER - But we really appreciate the chance, as I said at the beginning to have this conversation and we really do. I mean I know we filed the4200 bill very recently, um I wish we could have gotten to it sooner. Um but I really I have seen elements of what we're talking about in a number of pieces of legislation that are working their way through both the House and the Senate and we will obviously make ourselves available um any time to to talk about this as you contemplate how you want to factor this into the um into the work you do between now and july 31st and I and I really do appreciate the quickness of the of the hearing. Getting scheduled. Thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you, you're welcome and and thank you and my question and Stephen was not meant as a diskette was just I don't think anyone can argue that we all haven't been incredibly busy over the past two years.
The amount of stuff on4249 our plate so we appreciate it and you know it's nice to have a hearing where there's a lot of things that we both care about and a lot of things that we can agree on. So thank you for joining us and have a great day. Thank you. Same to you committee members and to you, madam Chair. Great. Okay, um moving on um I would now like to call uh Donna Mash Donna, are you on?
I am senator. Thank you.
Um
DANNA MAUCH - MAH - SB 2774 - Good afternoon, I'd like to thank chair Friedman, Chair Lawn, Vice Chair Chandler, Vice Chair Livingstone and honourable members of the4298 joint committee on health care financing. On behalf of the Massachusetts Association for Health thank you for the opportunity to provide testimony and support of Governor Baker's health care bill Senate seven. I'm sorry senate 2774. We salute the committee for your focus on the needs of people with behavioral health conditions with the surge in demand for behavioral health services and crisis care and the commonwealth. Due to this pandemic we need your interest and your leadership to improve our response more4334 than ever.
I earlier submitted written testimony covering key provisions of the bill and in the interest of time I'm going to focus my oral testimony on only two elements of Senate 2774 that provision to increase behavioral health and primary care spending by 30% over three years and the parity provisions. We applaud the Baker administration for its focus in this bill, which contains meaningful approaches to address the persistent obstacles that face people with behavioral health needs in the commonwealth. Among its noteworthy provisions, the bill calls4370 for an historic response and I think the secretary alluded to this to the health and economic impacts of chronic under investment in these areas. We support the requirement that health care providers and payers increase expenditures on primary care and behavioral health by 30% over three years.
This will address historical underfunding that results in frankly our inability to treat timely individuals and to treat these individuals effectively to prevent um conditions from deteriorating before they become4403 a crisis. Because the bill allows providers and payers to determine whether the increases will be focused on primary care or behavioral health spending. MMH advocates an additional proviso that an increase in health care entities behavioral health spending shall not be less than 30% of the baseline for their behavioral health spending. This is aligned with provisions in the Senate Mental Health ABC 2.0 Bill. We also note that that MMH supports establishment of the behavioral trust fund as outlined in the bill. I mean, our second point is about parody. MMH supports the provisions in the bill that better equip the department of insurance to enforce the Federal Mental Health Parity and Addiction Equity Act and also on State Parity laws.
We underscore the bill's4456 provisions that require payers to reimburse evaluation and management office visits at the same and no less than the average rate of reimbursement for evaluation and management office visits by primary care providers. We also support the requirement to submit utilization reports. the document requests for approvals, denials and denial appeals for covered behavioral health services consistent with all of health services. Finally, the requirement to submit a number of approved covered out of network services for behavioral health should be aligned with approved with required reporting and approved covered out of network services for non behavioral health services. I will stop there and thank you for considering our request with respect to Senate 2774. SHOW NON-ESSENTIAL DIALOGUE
Thank you so much for your testimony. Does and do any members have questions?
I don't see any. Okay, thank you.4519 Thanks for your time. Um, Next is a laura Pellegrini. Hi laura,
oops. You're muted. You're muted.
Great, Can you hear me now? Perfect.
LORA PELEGRINI - MAHP -SB 2774 - Good afternoon madam Chairwoman, Chairman Lawn, Members of the committee. My name is Lora Pellegrini. I'm president and CEO of the Massachusetts Association of Health Plan. Plants MAHP represents 16 member plans and two behavioral health organizations and we provide coverage to over three million Massachusetts residents. We appreciate the opportunity to testify today on the governor's bill and I'm going to just highlight a few areas of the bill that we strongly support. One is around primary care and behavioral health and setting expenditure targets. Um often primary care and behavioral health are not valued to the same extent of other care, such as specialty care that has reimbursed at a much higher level.
One need only look at the pandemic and the role the essential world that primary care and behavioral health played and continues to play in patient care. These providers are often our first line of defense and ensuring patients can access timely care, diagnosis and treatment and they help patients avoid costly emergency room visits. I think the governor was very articulate in explaining to you the reasons why these provisions are so important. Um as we try to right size um, the providers space and pay these folks appropriately. These long term inequities are really part of the CMS payment scheme, but this bill would seek to correct that and we would increase expenditures for primary care and behavioral health by 30% above aggregate baseline expenditures for three years ending in calendar year 2024.
The governor's bill requires that these expenditures being made within the confines of the cost growth benchmark. We think that is very important to be included in any legislation and we think about how this money could be used. It could be used to increase primary care and behavioral health reimbursement to invest um and improve patient care relative to screening and prevention to invest in non claims based investments such as telehealth electronic medical records and services to assist in closing health equity gaps. We could also establish new community based treatment options, including urgent care for behavioral health and we could really look towards efforts to integrate behavioral health within primary care practices. And that's something that my members very strongly support.
Prioritizing these investments will also hopefully attract a new generation of students who will seek careers in both primary care or behavioral health. And hopefully they would look to come to massachusetts to begin their careers because we value as a state these important professions. The governor's proposal would require careful implementation with input from payers and providers and um like we've done with our state's health reform efforts. The Legislature could provide an outline for these spending requirements, leaving it to the Health Policy Commission, the division of insurance or another4705 agency to work out the details. Um The other areas we want to talk about prescription drug transparency.
We strongly support these provisions making pharma part of the annual cost trends hearings, um with sworn testimony making them um subject to the attorney general. Those are currently provision that4725 both providers and payers have to adhere to. So it would be important to bring pharma into that space as well. And obviously um looking at allowing the HPC to4737 have authority to determine the value of4740 proposed drugs and established penalties for prices that are excessive or have had excessive increases would be very important. Finally surprised billing and facility fees my time is up but I will say that is very important surprise billing has been not acted on the federal level but you have an opportunity at the state level to do something more impactful and we would ask you to do that. So thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you. Um you can also if there was any other issues that you wanted to raise please feel free. I know you will4778 to send us written testimony. Yes we will provide detailed comments to you. Great thank you. I appreciate it. Any questions um for laura.
Okay seeing none. Thank you so much. Thanks for your time. Thank you. Um Michael curry.
Hello.
Hello. Nice to see you. Good to see you as well,4809 madam. Chair
MICHAEL CURRY - MLCHC - SB 2774 - Michael Curry, President and CEO of the Massachusetts League of4811 Community Health Centers. Chair Friedman, chair Lawn4815 and members of the committee thank you for this opportunity to testify. First I join you with a heavy heart today as Leonard Alkins, a good friend and mentor passed away yesterday of cancer which is why I and so many others are passionate about health equity and healthcare access as you may recall from 1962 to 2002 Mr. Alkins served in the Massachusetts State Senate working as clerk of the committee's on rules and administrative assistance to several presidents as well as the legislative aide and page. I join you in that building today in mourning the loss of your former colleague and my4854 friend and mentor and as and ask that you keep him and his family and your prayers.
Now I'd like to take a second to express my appreciation to this committee on behalf of our health centre members and their patients for your support for community health centers, our value, our challenges and our possibilities. We are also grateful to Governor Baker, Secretary Sudders and their administration for understanding and investing in the power of primary and behavioral health care to improve the health and well being of patients and as a result in lowering costs across the health care system. As the governor's secretary said today, these are smart investments that can curb costs and expand access. This is critically important to the patients we serve.
Patients who are more likely to be either hospitalised or die of covid 19 or feel it's lasting impacts suffer compounding chronic disease, carry the weight of untreated depression or struggle with substance use disorder or experience significant trauma as a result of violence or abuse. Health centers meet4920 people where they are providing a comprehensive primary and preventive services that our patients need in the communities where they live and they are key to4930 closing the widening health and equity gaps. They have been on the front lines of the pandemic to combat covid 19 through testing, treatment, contact tracing, vaccine education, outreach and administration and now lifesaving anti viral treatments and pediatric vaccinations.
Our health centers continue to be national leaders vaccinating racial and ethnic minorities in the commonwealth hardest hit communities. Over the last two years, the ability to deliver and be reimbursed for care provided via audio, visual and audio only telehealth has become paramount to our patients4965 and communities and to the financial viability of our health centers. We are happy that this legislation ensures providers can render telehealth without limitation to location or setting as long as it is it is compliant with federal and state laws governing where the patient is located. We want to again applaud this committee for your success ensuring that behavioral health and substance use disorder services will forever be reimbursed at parity with in person services in person visits.
However, we urge the legislature to permanently codify coverage and reimbursement parity for primary care and chronic disease management services as quickly as possible as those are set to end December 2022 just eight months from now. Health centers are already working tirelessly to reverse the impacts of delayed and deferred primary and chronic disease management care which is present, presenting as increased patient acuity. It is vital that the state continue coverage5025 and reimbursement parity for these services in order to not further exacerbate these inequities. We appreciate the governor's bill establishes a primary care, behavioral health trust fund, focus on focusing on advancing health equity.
Health centers consistently step up in their for their patients and their communities. But this quote unquote yes and approach combined with chronic historic underfunding strains workforce, our workforce and finances. We believe the goals of this new fund aligned with our Community Health Center Transformation Fund championed by chairs Seer and Honan. The Health Center Transformation Fund would create a pool of flexible, stable grants for otherwise unfunded urgently needed health center investments. The fund would support technological and operational5070 projects that help transition to more integrated primary care, enhanced data collection and and help and help expand and diversify the workforce pipelines in line in line with your concerns chair Lawn about growing the pipeline.
We urge swift adoption of the transformation fund recently favorably reported by this committee. Safety net providers are experiencing a profound, profound workforce crisis. Our health centers have substantial dental vacancies and the ability to hire dental therapists would help immensely with dental access the flexibilities in this legislation and expand the scope of practice for physicians assistance and5110 podiatrists will help patients receive more timely care. Overall we sincerely appreciate the governor and the administration for again, elevating the need for increased investment in primary and behavioral health care with our health care system to catalyze the real and lasting change we need. We urge the committee to seriously consider this proposal and the others noted in my testimony on health center funding, telehealth and growing our health care workforce. Thank you for this committee's time and steadfast support.
Thank you and thank you. SHOW NON-ESSENTIAL DIALOGUE
And to all the members of your um associations for all of the work that they've done and the incredible value that they give to our commonwealth to ensure access and inequity. So thank you. Um are there any questions
mr curry?
FRIEDMAN - Now um just um so it again, if you if you had to pick5181 up the pieces of this bill that were going to be the most effective in the shortest amount5186 of time would be um the primary care, behavioral health um expenditure is that that's the...
CURRY - Um well, what we knew, and again, credit to the governor's secretary when they advanced a very similar proposal a few years ago was that increased investment in setting a threshold for increased investments in primary care and behavioral health was a, a game changer quite frankly. We knew that as you and I have to discuss this madam chair many times before investing upstream and I would consider primary care upstream. Uh and we know that this legislation mirrors that proposal. I would say again, the trust fund is a key part of that the telehealth piece. I mean, there's so many pieces, I almost feel like Secretary Sudders you almost struggle to find one particular thing because there's quite a few things here that are critical.
Um And then I know we've been beating this drum for a long time but scope of practice my members are saying it across the commonwealth. We need to finally move on scope of practice bills because that will help there's one tool to respond to this workforce crisis that we're experiencing in health care. So again, I lift up5261 all those provisions. SHOW NON-ESSENTIAL DIALOGUE
Okay, thank you. Thank you. Any other questions. Seeing none. Okay, um Dr Alan,
Good afternoon, Good afternoon
CAROLE ALLEN - MMS - SB 2774 - Chair Friedman, Chair Lawn and members of the committee. My name is Dr. Carole Allen. I'm a pediatrician, retired after 37 years of practice in three different clinical settings and a former commissioner on the Health Policy Commission. I'm speaking today as president of the Massachusetts Medical Society representing over 25,000 physicians, residents and medical students across Massachusetts. Thank you for the opportunity to testify today on this important bill. We will submit written testimony, but I'd like to emphasise a few points. The medical society commends Governor Baker and and the Legislature for proposing 30% increases in primary care and behavioral health5329 spending.
We view these additional investments as crucial to improve population health and ultimately reduce overall healthcare costs. For me primary care is where trust and connection between patients and their physicians are developed and nurtured over time. These relationships frequently result in better clinical outcomes with fewer emergency room visits, mutual clinical decision making, better compliance with prevention and treatments and frankly better health. It is important that primary care be patient centered, comprehensive, coordinated, accessible and focused on quality and safety. What is not clear from the language in Senate 2774 is how primary care is defined episodic illness treatment, targeted screening tests and procedures and immunizations in themselves do not constitute what we consider to5389 be a longitudinal meaningful primary care relationship.
The need for increased spending on behavioral health care is urgent. Currently, children and adults in crisis often cannot find appropriate behavioral health treatment and counselling, boarding levels and EDs are astronomical. While beds in mental health facilities stay vacant because of inadequate staffing. Many psychiatrists and psychologists do not accept health insurance leading to inequities in access to appropriate care. We hope you will be creative in funding these increased investments and establishing comparable baselines across systems. Some other very quick points. We appreciate the effort to reduce administrative complexity and practice, for example, by increased telehealth flexibilities.
We strongly support the requirement that all insurers accept the same core set of meaningful quality metrics and we support the oversight of pharmacy benefit managers and cost growth accountability for pharmaceutical manufacturers. We would be happy to work with the legislature5458 to flesh out how increased investment in primary care and behavioral health might be implementing implemented excuse me without harming access to other crucial health care services. Thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you. And um will you be submitting written testimony or have you? We will be submitting written testimony.
Great, thank you. Would be really interested to see the primary care definitions.
Any questions from the committee?
No. Okay, well thank you Dr alan, it's great to see you. Great to see you. Thank you very much. Chair Friedman
um Next we have Marcia Fowler and Dave Madaro photo.
DAVID MATTEODO - MABHS - SB 2774 - Thank you, madam chair, Representative Lawn and members of the committee. I'll go first and then I think Marcia will follow up quickly with our testimony. My name is David Matteodo and I'm the executive director of the Mass Association of Behavioral Health Systems testifying today on behalf of the governor's bill with my chairwoman, Marcia Fowler, who is also the CEO of Bornwood Hospital. I'm just going to make a few points and basically the headline of our testimony is we strongly support the goals of the governor's bill. And the reason why it's so important is because for decades the behavioral health system has been underfunded and over managed and we're really seeing the results of that now unfortunately uh since Covid.
And you know, this is a very timely bill, um we are seeing pressures5571 on our system that we haven't seen in decades and I've been in this position5577 for over 30 years and we've5579 never experienced stressors on our in patient system but we are now. We represent5586 incidentally 47 hospitals all behavioral health substance use and psychiatric as well as units in general hospitals. There's four areas that we're really seeing incredible pressure. One is the demand for services on a given day there are 6 to 700 people boarded in emergency rooms if you can believe it waiting or needing some type of behavioral health care. Many need inpatient care. Some youths5619 wait in the Legislature of course knows this, they wait for days and sometimes even weeks for an inpatient bed.
Why is that? We have empty beds because of workforce issues. We really appreciate what the Legislature stepped up5637 with the ARPA Bill in the 400 million for behavioral health. That's going to be a real shot in the arm. We haven't gotten any of that money just yet, but the trust fund is going to get working I think hopefully very shortly now that that issue was addressed last week by the Legislature and some of the other loan payback and loan forgiveness and so forth. Hopefully that will be coming soon. So that will really help. So we incredible demand for services while we also have these workforce shortages and on a given day we have several 100 beds offline because of workforce shortages. Close to 400 beds offline simply because of workforce, mostly nurses, nurses, mental health workers and social work.
Um the third, the third major area we're seeing is increased security. The patients we're seeing are very, very difficult. We have a lot of one to ones we have to do use private rooms on occasion and that further reduces our capacity. Finally discharged issues on a given day we have 150 state clients waiting for some type of placement close to 100 of those are DMH patients waiting for a state hospital. We've given the ways and means committee language to expand the DMH beds so that we don't have people waiting for months and in some cases if you can believe in over a year for a DMH state hospital bed and that again restricts access. We have kids waiting as well for DCF placements. Two things in particular for the bill that we would request.
One is the expansion of the physician assistance uh to allow them physician assistance to authorize admissions and certify restraints that goes a little further than the governor's bill. And secondly, um the support our budget language to expand the DMH system by 30 beds. That would really help us in in the long run discharge some5771 of these patients. So thank you and I think my colleague Marcia5776 Fowler is going to try to testify, although I just got a fax from her and she is having some computer problems. I'm not sure if she's able to unute herself. Marcia. Well, I guess she can't. I probably used up all5796 our time anyway, so I'm I appreciate this. I appreciate, we5799 appreciate so much the attention this committee and the Legislature has given the behavioral health.
I really thank you for all5807 your efforts. It's going to pay off were struggling but we're going to get through this. We're doing the very best we can. And your support in this Legislature is hugely recognized and appreciated. Thank you.
FRIEDMAN - Great. Thanks. Dave. Um, I do have one question you were asking for 30 additional DMH beds of the 100 or the a couple 100 that are offline or 400 that are offline are a number of those DMH beds?
MATTERODO - No, those are in our system. I can really summarizing for you. There are 660 DMH beds. They're all full. DMH runs the capacity and it's mostly because of forensic patients. They get the courts send them patients and they take they take precedence over the folks that are waiting in our hospitals. So those, those are all full in our system there's just shy of 3000 beds. 2988. We run a census of about 2,350. That gap, The biggest piece of that gap is because of staffing. So that's what the ARPA money was for and Mass health has been very influential as well.5888 They really stepped up and given us money for workforce. The bigger problem we're having honestly, we're not seeing the applicants and we, we we we will have employment fairs and recruitment for nurses, for example, will get, you know, one nurse shows up. Maybe if we're lucky, it's it's very, very difficult to attract people to this field now. SHOW NON-ESSENTIAL DIALOGUE
Okay. I just wanted to check. Thank5917 you very much. Are there any other questions?
Okay, thanks so much for your time. Thank you very much.
Um, the next person is Ellen the paolo
honoring
Thank you. I'm getting right on. Here we go. Thank you.
ELLEN DIPAOLA - HCM - SB 2774 - Thank you. Uh and thanks for the opportunity to voice my support here for for 2774. My name is Ellen DiPaola I'm the president of Honoring Choices Massachusetts were a consumer nonprofit. And our job here is to inform and empower adults to exercise their fundamental right under Massachusetts law to accept and refuse medical treatment and to be able to write that down in their very own advanced care plan. We partner with hundreds of healthcare providers throughout the state our community partners who work directly with adults and families to deliver that care to to folks with serious illness and advancing frailty to make sure we know and can honor their choices.
Our community partners consistently report that unfortunately5992 are most programs in medical orders for life sustaining treatment is highly dysfunctional and at times totally fails to know and honour the choices of the individual in of individuals. So I want to just give you two quick examples to illustrate this. So a primary care doctor and their elderly patient with a terminal illness signed a paper MOST form and that really is to indicate what that patient's choices are for life sustaining treatment. He was clear he chose no CPR no, no resuscitation. If his heartbeat and his breathing stopped, he wanted a peaceful, dignified national uh death. His family totally supported his decisions.
6034 Unfortunately,6034 the patient fell gravely ill over the weekend and CPR was attempted at the hospital which is going to happen while somebody looked to see if there was a paper MOST form it was in the medical record. It just wasn't findable. The primary care physician was not alerted to this til monday that her patient was now in the ICU, hooked up to several machines to sustain his life. The very nightmare that he and his family tried to avoid. The family was quite devastated with guilt. That's a typical scenario. Let me offer you6066 one more. The second example, a family member who called Honoring Choices to support reported that a loved one with a lifelong disability and an underlying progressive serious illness arrived at the hospital having signed a MOST form saying yes, I want6081 CpR I want to be revived if my heartbeat and breathing stop.
But no to ventilation with this conflicting and confusing medical instructions on an antiquated MOST form the attending at the time on call said due to the man's disability and his suspected quality of life, that they would not recommend CPR the family was beside themselves and was scrambling to fight for his right for treatment. So, you know, we consistently hear these similar scenarios that we have a failed program but guess what? We have a wonderful systematic change right at our fingertips here. The good news in Massachusetts is that we have everything6120 in place to upgrade this antiquated6122 MOST program to a nationally recognized pulsed program, POLST and with that program comes keep components such as information training and an electronic registry.
The registry would allow participants to access a national post form and in minutes with clear instructions to deliver the type of timely equitable care that is there according to patient choices and to mitigate discrimination, harm and suffering. So we have everything we need here. We have the funding, we have the support from national, we have an incredible group of sustained statewide stakeholders who are all in favor of this upgrade. So we ask that you favorably report out on this to very simply authorize mass EOEA to upgrade to a pulse program.
FRIEDMAN - Excuse me. Is this part of the bill that we're hearing today?
DIPAOLA - Yes, it is. It's actually in the one of the6180 last sections of the bill. SHOW NON-ESSENTIAL DIALOGUE
thank you. We will take a look at that. Thank you. And if I can respectfully6191 ask my colleague Dr ERIC from is trying to juggle patients in this call. So if he can be heard, that would be terrific. Thank you doctor Very actually, I'm sorry, we got to6205 stick to the rules and if if you didn't sign up, we I'm sorry. Um it's not out of lack of interest. It's just that he's on your list. So he is dr erIC for me.
Okay.
Okay, sure, go ahead. Dr sorry, I didn't see you. You're not as part of well. Okay, go ahead. But quickly, please thank you. Can you hear me okay? Uh, I'm here in my clinic.
DR ERIC ??? - SB 2774 - Thank you, Chair Friedman and chair Lawn and the vice chairs and members of the committee. So I think I'm going to follow up on what Ellen said. Uh, and I think this goes directly to your question, are there pieces of this bill uh that um, could be um, focused on and we're focusing I think the part that we're focusing on is down there in Section 22. Uh, and it's regarding authorizing MOST to pulsed as as Ellen was saying. And I think this is, I think this is an easy quick win for6273 the state of Massachusetts and I'm really grateful for the opportunity to voice my support as well. Again for this Section 22 of House Bill S2772. So Ellen already told you a little bit about what MOST is, I guess what I would like to say is Massachusetts got a great start with MOST about 10 years ago.
It was a pilot in Worcester. It was so successful that um, the entire state adopted it without any change in legislation or funding. The problem is is that it has not changed the way the pilot was set up has not changed in 10 years. And as you can imagine with all the changes in health care6318 and what not since then now the program is sort of desperately out of date and unable to meet its great potential. I also have patients just like the ones that Ellen described, one of mine was 92 years old with Alzheimer's who was seen in the emergency room. She was sent by her assisted living facility because she had belly pain. A surgeon evaluated her and appropriately said, well this this lady is too frail for us to operate on but maybe we can fix this endoscopically.
They admitted her to try that procedure but she was there overnight and in the middle of the night she became confused and short of breath. And so the ICU doctor put her on a ventilator and it was the next morning that her daughter who6362 I think was in her 70s showed up and very meekly asked why her 92 year old mother was on a ventilator when she had very clear MOST orders saying not to. And it just boiled down to, it didn't occur to them, even though she was quite frail and quite ill to look. But it was there and and our health system is designed to work for people who can speak up and decide for themselves, but many people who are sick can't and to avoid doing things to people that don't want them to avoid failing to do things to people who do want them.
We need a trustworthy system which we currently do not have, but we have everything as Ellen said, everything is teed to there is funding both from Blue cross blue shield $450,000 and $2.2 million earmarked in ARPA funding. There is a wonderful and dedicated expert and experienced advisory panel uh broad stake stakeholder engagement and we need your help. We think that EOEA is exactly the program uh to to take charge of fixing MOST and are grateful to be offer listening to us. SHOW NON-ESSENTIAL DIALOGUE
Thank you, thank you, thanks for your time. Um Are there any questions? We will take a look at those sections? I'm sorry, I did not remember them in reading. Um Okay, um thank you. Next is Zach Stanley
ZACH STANLEY - MB - SB 2774 - Hi, good afternoon Chair Friedman ,Chair Lawn thank you for the opportunity to testify today. My name is Zach Stanley I'm the Chief of Corporate affairs here at Mass Bio. We're a state based trade association representing over 1500 members across the life sciences industry. Um in 2019 the legislature passed a bill giving Mass health additional tools to seek supplemental rebates on6480 prescription drugs under that law which was originally proposed by Governor Baker Massachusetts now has some of the most6487 extensive Medicaid drug price transparency laws in the country. And now the administration is back with a series of proposals that seek to regulate drug prices in the commercial market in a similar manner.
There are two reasons why we have Mass Bio and our members disagree with this approach and oppose these provisions. Number one is drug spending growth in the commercial market in particular is very limited and quite stable. According to CHIA's annual reports of the last two reports, total drug spending net of remates in the commercial market alone grew by 2.6% in 2019 and 2.5% in 2020. This data is broadly consistent with what we're seeing nationally and remains below the state's healthcare benchmark, progressive policies seeking to control spending on drugs and the commercial market is simply not necessary right now. Number two, seeking to lower the list price of drugs does not correlate with reduced consumer spending on drugs.
Drug manufacturers do not control drug formularies or patient out-of-pocket expenses. Insurance companies do this legislation that seeks simply to reduce the list price of the drug does not mean that an insurer will turn around and reduce what patients are required to pay out of pocket. This is not to say that there6567 are no problems at hand. People do have trouble affording their medicine because of the ever increasing health insurance premiums, deductibles and out of pocket costs and that really should not be the case. We have shared goals in that regard. Our belief is the legislature should be focused on policy solutions that will have a direct impact on reducing the patients out of pocket costs. The best place to start in our view is to look at the $2.7 billion in rebates that were paid from manufacturers to insurers and PBMs across all payers in 2020 and use that money to reduce out of pocket costs for consumers at the pharmacy counter.
We have legislation that we're strongly supporting in this session, House Bill 1224 that will accomplish just that and we encourage the legislature to continue to look at proposals in a similar vein. As this debate continues on, we6617 encourage to be excuse me, we look forward to being part of the conversation and part of the solution to our shared goals. Thank you for the opportunity to testify today.
FRIEDMAN - Thank you. So I have to ask the question if the commercial drug prices have not gone up that they are very limited and they are quite stable. You won't have any problem with us actually reporting that out via CHIA and the health policy commission?
STANLEY - You know, from our view, I think CHIA already is providing that data. You know, our question would be, I'm sorry, excuse me.
FRIEDMAN - Finding it not as part of the cost growth benchmarks for the, you know, the package, they are looking at that because they have access to some data but then you won't mind being included into that um into part of the cost grow benchmark entities that we look at?
STANLEY - Senator, you know, as you are aware, you know, we have filed drug price transparency legislation this session as well that does include having the drug manufacturers part of the HPC annual healthcare benchmark hearings.
FRIEDMAN - Okay, so you're, you're in favor of that and have no issue with that part of it?
STANLEY - I think as with all these issues, you know, the details matter. So I can't say that a broad scope, but there are ways that we believe that we should be included in the hearings.
FRIEDMAN - Okay. I just find it interesting that we keep hearing from the pharmaceutical industry that they are not the problem, but when we go to treat them on the same level that we treat our hospitals and our insurers, we get pushed back. So I just kind of want to point that out.6721 That's a problem that I'm having trouble getting my head around. Um, so anyway, thank you. SHOW NON-ESSENTIAL DIALOGUE
Are there any questions any comments for Zac?
No. Great, well thank6731 you and thanks for your time. Thanks for being here.6738
The next on the list is
Alyssa Van jelly from um health Care for a Hi Alyssa.
ALYSSA VANGELI - HCA - SB 2774 - Hello, good afternoon Chair Friedman, Chair Lawn and members of the committee. My name is Alyssa Vangeli. I'm a co director of policy and government relations at Health Care for All a statewide organization that advocates for health justice in Massachusetts by working to promote health equity and ensure coverage and access for all. Thank you so much for the opportunity to testify today on Senate Bill 2774 an act investing in the future of our health. This bill takes a number of important steps to improve healthcare access, affordability and equity for residents of Massachusetts and among the many important issues addressed in this bill would like to highlight our support for a few key proposals.
First, we strongly support addressing the rising costs of6793 prescription drugs. The Baker administration has been a long standing partner on efforts to contain prescription drug costs in the commonwealth. The Mass health drug pricing policy, which was just mentioned that passed in the state's FY20 state budget has been highly successful, saving the state over $171 million through rebate agreements with 17 manufacturers for 50 drugs. We support extending this policy to the private market to bring pharmaceutical companies more in line with the cost containment measures for other industry groups such as hospitals and insurers. The legislature now has a number of viable vehicles to rein in rising prescription drug class, including Senate bill 2695.
We hope action can be taken before the end of the session so that individuals and families can afford needed medications. Second along with our partners in the Children's Mental Health campaign, we support the bill's provisions to increase investments in primary care and behavioral health and strengthen enforcement of the state and federal mental health addiction parity laws. These provisions and others are directionally aligned with mental health legislation passed by the Senate and proposals currently under consideration in the house. The longstanding underfunding of primary care and behavioral health are major contributors to access barriers for people across the state. The covid 19 pandemic has intensified the need for behavioral health services, especially among children and adolescents,6875 and more capacity is needed.
Third, we strongly support the provisions that address escalating health insurance premiums for individuals, families and small businesses. These increases lead many residents with private insurance to spend a greater portion of their income towards health care and places a significant strain on employers who want to provide quality health care coverage for their employees. The bill would give the division of insurance additional tools to modify proposed premium increases that are unjustified a process that has been highly effective, for example, in our neighboring state of Rhode Island, which has a similar rate review policy. Fourth, we support the inclusion of language that takes steps to protect consumers from surprise medical bills and establishes a default payment rate for certain at a network services.
The language reflects recommendations of the EOHH's reported6922 at a network rates. And while the note while the federal no surprises act as an important step forward, we've already seen some challenges with delays in implementing regulations and potential complications with enforcement. We also have concerns that the federal law relies on6936 arbitration rather than an established default rate, which could internally to higher overall system cost due to the potential for higher rates. These increased costs in turn could translate to higher premium increases for people and employers. A state level default rate would ensure a fair streamline process so people are not only protected from unforeseen surprise billing costs but also from higher overall system costs.
And finally, it's important to address oral health care access. Despite the full restoration of adult dental benefits in Massachusetts, access to oral health care remains a challenge for too many. We6970 support the provisions in the bill to license midlevel dental providers known as dental therapists who can provide critical care in communities. This should be done in a way that ensures a pathway into the profession and meets national accreditation standards. We thank the governor and secretary Sudders for their leadership and look forward to working with them and the legislature to address these proposals before the end of this session. Thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you so much. Are there any questions
from the committee?
No, thank you. And I know you'll be you did or will submit written testimony so we can see the details. Great, Thank you. Okay. Um, nick Doherty
my neck. I'm sure. How are you?
NICK DOHERTY - PHARMA - SB 2774 - Good afternoon members of the committee. My name is Nick Doherty I'm the director of policy at pharma for the New England region. Pharma represents the country's leading innovative biopharmaceutical research companies. Since 2000 Pharma member companies have invested more than $17039 trillion in the search for new treatments and cures, including an estimated 91.1 billion in 2020 alone. I'm here to testify in opposition to a number of the provisions included in Senate Bill 2774. We did submit a very detailed statement to the committee ahead of the hearing that provides a greater overview of our concerns and for the sake of the time, I'll just adjust a few of those here.
We completely agree that patients need concrete reforms and we support reforms that are in the best interests of the patients, such as lowering their costs at the pharmacy counter, ensuring access to medicines and protecting the work being done to end covid 19. However, at senate 2774 includes several worrisome provisions that we consider government price setting, which could jeopardise patient7085 access to medicines they need. Patients and countries that allow the government to arbitrarily decide the value of medicines in which diseases are worth investing in, get slower access to fewer breakthrough medicines. In countries with government price setting controls in the marketplace such as the United Kingdom it can take over a year from the time the drug is approved to7107 the time it is available to patients.
Some countries have a delay of over three years for a cancer drug to be available to patients. More specifically, we believe proposals to arbitrarily cap pharmaceutical prices of patented products would violate federal constitutional principles and also does not accurately capture the price of the drug. For example, Senate 2774 seeks to implement stiff penalties for certain price increases in wholesale acquisition cost or list price. However, bio pharmaceutical companies negotiate substantial rebates and discounts with PBMs and health plans and these price concessions are not reflected in list prices. Pharmas increasingly concerned it's a substantial rebates and price concession paid by manufacturers, which on a national level totaled approximately $236 billion in 2021 and 2.5 billion in massachusetts alone do not make it to patients to offset their costs at the pharmacy counter.
Many stakeholders determine what a patient pays for medicine, including insurers, PBMs, wholesalers and government agencies like Medicaid. The important role that these entities play in setting drug prices and drug coverage is overlooked by the requirements of this legislation. Additionally, we are concerned with the language that grants the HPC broad authority to determine the value of a drug and impose significant penalties for exceeding HPC's value. It's based on bad criteria which again raises constitutional issues uh to piggyback off what Mass Bio said, the growth of net prices which reflect rebates and discounts has been in line with or below inflation for the past five years. Specifically, brand that prices declined 2.9% in 2020 of course, isn't necessarily reconciling what patients are feeling at the pharmacy counter, which is important why we look at all entities within the supply chain.
In 2020 manufacturers retained only 49.5% of brand medicines while other members retained 50.5. Of course I'll stop there and ran out of time. We recognize the challenges faced in Mass and are happy to help anyway we can
FRIEDMAN - Thank you just two quick questions what part of this bill does um, price setting for pharmaceuticals and which part of HPC um, can instill heavy penalties if you if they don't agree with the value of a drug. I know there are penalties for not engaging. Um but what part of it has HPC implementing heavy penalties.
DOHERTY - So in Section7270 6 of the bill, this failure to comply with the aggregation of information requested by the HPC or in um its participation in affordability plan, they would be allowed to levy a $500,000 fine on a manufacturer.
FRIEDMAN - Okay. We'll be sure to go back and check because what I believe is that that is for non engagement, not for the ultimate outcome of whether7301 prices a drug, the value of the drugs. So we'll make sure that that that is not the intention I believe.
DOHERTY - Okay, and happy to work with the committee.
FRIEDMAN - Where is the government price setting part of this.
DOHERTY - So and then looking at the excessive price penalty and determining the state, determining that it exceeded a particular amount and then having a fine. We are viewing that as a price control. Of course and a price control we believe runs counter to federal law. There is a case in 20077343 Bio versus the District of Columbia where the US Court of Appeals overturned a. DC Law that imposed price controls on branded drugs. And the reasoning behind that it was a lot that conflicted with an underlying objective of federal patent framework and that undercut the company's ability to set prices for its patented protections. SHOW NON-ESSENTIAL DIALOGUE
Okay. Um we'll take a look at that because that is not how I am reading the language but we'll take a look at it. Um
And we'll look for your
your detailed7376 um
your detailed testimony. Okay. Does anybody have any questions for nick?
Okay. I just have to point7386 out7386 that I
I have great respect for pharma and I especially in the past several years as you pharma has played such an important role. I do also want to point out that our universities and our government and our public entities have been any often equal7415 partner in that um in those breakthroughs in those discoveries. So um we all should figure out how to work together on this. So thank you. Thank you for having me um
Mike fester.
MIKE FESTA - AARP - SB 2774 - Hello senator Chair Friedman and Chair Lawn and members of the committee. I want to pick up on7440 the7440 theme you just made you know when I think we're hearing today is an appreciation frankly of the bipartisan nature and the bold nature of what's before the committee today. This legislation is in many respects bold in the sense that it is addressing some of the underlying weaknesses in the current health care system and I know the senator as you probe some of these questions you're picking into those areas and so what I want to do in this brief testimony is to assure you number one we have written detailed testimony. So I'm just going to jump right7478 into a couple of highlights. On the category of HPC and drug pricing, costs and transparency.
Fundamentally we know I mean however you talk about policy on the ground in the street and for the 750,000 members of AARP in Massachusetts, drug prices and the high cost of position drugs generally is a major problem. And to the extent that Massachusetts can continue to lead in protecting its consumers and striking the right balance. We applaud you for doing so in provisions Sections 5, 6, 11, 14, and 20. Those specific provisions that we are happy AARP to support in the governor's bill. The second category that's been spoken of with regard to behavioral health and primary care Section 24.1 we support that provision for obvious reasons I hope. Telehealth Section 37, Medical Licensure Compact Section 53, Modernizing Data Standards Section 54 the whole category of surprise billing Section 69, 71 and 72.
I just want to conclude by saying that in many respects as you try to figure out as a committee where you can land in a bill that is going to capture many of these priorities in a comprehensive way. I just want to applaud you for your leadership, both the chairs of this committee as well as the committee itself. You have really propelled healthcare policy in this state across the country to be a shining light and a real guide and as the Congress struggles to even do something like Medicare price negotiation because of all the cross currents of politics and all the stuff you are well aware of in our state, I think we should rejoice in acknowledging that there is a genuine bipartisan effort led by the governor and led by members of this committee to try to get to the place where healthcare policy is rational, it's fair and it is effectively meeting the needs of the commonwealth citizens. So thank you for that. And as I say, we're submitting full testimony on the provision that I've highlighted in this brief in these brief remarks. So thank you. SHOW NON-ESSENTIAL DIALOGUE
Oh, I think you're on mute. Thank you. That's very nice of you to acknowledge us and probably farmer may not quite feel the same way you do, but we have a different view.
Are there any questions for mike? No. Okay, thank you. It was nice to see you. It's good to see you, Madam Chair jennifer. Mcnary jennifer are you here? I am. I'm here on audio.
JENNIFER MCNARY - CONCERNED CITIZEN - SB 2774 - Coming to you live from the school pickup line. I'm sorry that I'm not on on camera for you, but I had to pick up my children. Um, I live here in Saugus with my four biological children and to foster children. Three of my sons live with rare diseases, uh Duchenne7667 muscular dystrophy and primary immune deficiency. And I am here today representing just my family despite wearing many hats in this rare community and some of the folks on the call, our, our colleagues of mine on our deck but I'm representing myself and my children um, through my journey as a rare disease parent and caregiver, I've become deeply familiar with our commonwealth health care system. The ways it does and does not support patients who rely on it and for this reason, I am speaking today against SB2774 as currently written.
This bill needs to be amended to include strong patient protections, including a ban on the use of the quality adjusted life year or quality. This is necessary to ensure that the bill does not preclude individuals like my three sons from accessing the treatment they need, which have been7716 prescribed by their physicians. 20 years ago when my older sons were diagnosed with Duchenne muscular dystrophy there were no treatments. I was told to take them home, love them because they would not survive into adulthood. My family has been lucky when my son Max is nine, he enrolled in a study that resulted in the first approved disease modifying treatment for Duchenne. The FDA approved therapy in part based on Max's own benefit in the clinical trial.
Yet Mass health never approved7742 Max for access to his treatment commercially prompting me to enroll him last summer in another clinical trial to ensure that he has access to a treatment. We have lived through a major shift for Duchenne. We now have treatments. The access to these treatments has continued to be a major challenge for my sons and others in the state. Recently in their quest to lower drug costs, policymakers and players keep looking to easy and simplistic formulas to determine the value of a drug. Typically, this comes in the form of cost effectiveness analysis which utilize a metric called the quality adjusted life year or quality. The quality is concerning. It places a lower value on treatments that extend and improve the lives of people with disabilities and chronic illness like my son.
Using this quality formula, a year of life lived with Duchenne is valued less than a year7791 of life lived in optimal health. It was incredibly troubling when Massachusetts gave the HPC the ability to determine the appropriate value of a drug as evidence pointed to the fact that they would rely on the quality. My concerns were validated when HPC moved forward and signed a contract with Icer to assist them in developing the framework for valuing drugs. SB 2774 would expand their authority to determine the prices for the drugs beyond just Mass health into private payers as well. This is not hypothetical and I urge the committee to understand the real harm the use of the quality adjusted patients. During the Mass health denial appeals process when seeking to access treatment for my son.
The nurse representative referenced the value of drugs for non ambulance patients being zero even if it were free. This was an exact reference to the voting panel of Icers' reference during the public meeting, the comments governor Baker made earlier with a focus on primary care as a way to both lower emerging and chronic illness costs and to increase the health members of the state. In the case of rare disease patients, primary care includes early initiation of innovative cutting edge7855 disease modifying therapies. As the secretary mentioned earlier, Massachusetts sets the stage for country being a leader in innovative new therapies. We should also be a leader in drug access removing quality from this conversation is a reasonable step in that direction. Thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you. Thank you very much for your testimony. Are there any questions?
No. Okay, thank you jennifer.
Um next Jim Brennan and dR ken care.
Good afternoon madam Chairman and committee members.
JIM BRENNAN - MUCA - SB 2774 - My name is Jim Brennan and I'm the managing partner for AFC Urgent Care in New England. AFC Urgent Care has 21 urgent care centers out braiding in Massachusetts and has been for more than 12 years, including locations in Springfield, Twister. I'm testifying today on behalf of the Massachusetts Urgent Care Association. Collectively, our brands represent almost 20% of the urgent care market in Massachusetts. We oppose the urgent care licensure mandate in this bill as written because it would negatively impact our ability to provide high quality, convenient and accessible care. For patients who cannot wait to see their PCP but don't need to go to an7957 ER we provide access.
We're open seven days a week, nights, weekends and holidays. Additionally, our technology allows us to provide continuity of care services for the patients. Primary care provider. All of our centers are staffed by licensed providers and offer lab services and x-rays that are also licensed by the state. Most of our centers are also accredited by the Urgent Care Association of America, an industry standard for quality and safety. We share the state's goal of making sure patients expectations are met when they walk into an urgent care. That said, we don't believe licensure is the way to accomplish this. Especially since provider groups such as primary care, orthopedics, cardiology, radiology just to name a few have no such requirement. Instead of creating a new licensure category, we encourage the Legislature to recognize the urgent care associations of America accreditation process and definition of urgent care which have been adopted by more than 10,000 centers across the country.
These reflect the full scope of our industry and give patients the confidence to know what services they can expect and what are available to them when they walk through the doors. Our centers are located and convenient and accessible areas like strip malls, neighborhood offices. Many8038 are not currently licensed as clinics because they8042 meet other definitions of ownership and control or they don't comply to the DPH physical plant requirements. In most cases renovating these facilities would not be financially or structurally feasible and would have8055 no meaningful impact to patient care.8057 This bill does not recognize the unique settings of our centres and does not speak to the need to grandfather in pre existing centres.
I think licensure is already a significant deterrent to developing new centers in the state in densely populated urban areas much of the real estate is preexisting multistory and has limited parking. This makes it extremely expensive or impossible to comply with the many, many of the current clinic requirements. These barriers contribute to health care, inequities and adversely impact our ability to serve these communities. Identifying locations, negotiating leases and building out new facilities all require upfront capital and the confidence that we can see our project through to completion. The current process for licensure is long and cumbersome. I personally have experienced waiting for months for licensure to inspect the center that was fully built equipped and staffed.
During these months I was paying rents, salaries and benefits for a center that remain locked and unable to see patients experiences like this are decentivising further investment8126 by many of our members in Massachusetts, leaving patients with fewer and more expensive alternatives for care. For these reasons we urged the legislature to reject the urgent care licensure mandate. We thank you for your consideration and look forward to continuing this conversation. SHOW NON-ESSENTIAL DIALOGUE
Thank you Dr King Care I didn't care. Yes, Cancri.
JEANNIE KENKARE - POUC - SB 2774 - Thank you. Chairs Friedman, Lawn and all the members of the joint committee for allowing us to testify. My name is Dr. Jeannie Kenkare. I am the founder and chief medical officer of Physician One Urgent Care. I started our practice in 2000 and eight to address two major issues one over utilisation of our emergency departments for non emergency conditions and to to address inefficiencies in our primary care system. I represent the urgent care industry and providers committed to improving access to high quality affordable health care. I am deeply concerned that the urgent care provision in this bill will immediately and negatively impact the tremendous progress we have made to improve access to affordable care. This legislation would in fact reduce our ability to operate and grow, drive up the cost and limit access to medical care.
As a physician owned practice I'm opposed to creating a requirement for urgent care licensure. We already have the commonwealth's oversight of our provider licenses as well as comply with laboratory and X-ray licensure. Currently, about 25% of the urgent care centers in Massachusetts are8218 licensed as a healthcare clinic. Most centers like ours meet another definition of ownership and control licensing an urgent care centre based on things like the width of our hallways, the location of sinks or the number of parking spaces has no meaningful impact on patient care. It just drives up building costs and limits where we can be located. After two years of being on the front lines of the covid pandemic. It's disheartening to see the urgent care centers singled out for additional regulation when many of our fellow providers have no such requirement.
Urgent care operators never8252 closed their doors during the pandemic. We helped8256 to keep people out of the ER we were the first to offer large scale covid testing. We've administered tens of thousands of covid vaccines. We've been ahead of the curve in offering telehealth services and we continue to lead the way and offering innovative and effective treatments at rates at 20% of the cost of an ER visit and on par with the primary care visit. A major win for patients in accessing this care was the legislature's action last session, which removed the PCP referral requirement for mass health patients seeking urgent care treatment. This helped to improve access to high quality care for the underserved and at risk populations because of this, we have seen an increase in Mass health health patients in urgent care centers ranging from 30 to 88% per center.
8304 Historically,8304 approximately a third of our patients either would not identify with the PCP or haven't adequately met with their PCP. But since the start of the pandemic, this number is closer to 40% as many patients first point of contact with the medical system, urgent care centres serve to ensure that patients get timely and appropriate follow up with their PCP. And we have systems in place to help those without one get one. So in summary urgent care provides a solution to the challenges the commonwealth faces with respect to providing convenient access to high quality affordable care. And I implore the committee to consider how8340 to remove the barriers for urgent care practices and allow us to innovate and make improvements to our current high cost and inadequate health care system. SHOW NON-ESSENTIAL DIALOGUE
Thank you. Are there any questions from the committee
hearing? None. Thank you appreciate you coming and we look forward to your written testimony. Thank you so much. Thank you. Um Marshall smith.
MARSHALL SMITH - IMLCC - SB 2774 - Good afternoon. Um my name is Marshall smith and I'm the executive director with the Interstate Medical Licensure Compact Commission. We've all suspended written testimony in support8380 of the bill. Um I appreciate the opportunity to testify um virtually in favor of Senate Bill 2774. The I got out of place in my notes. Sorry, the compact like other healthcare compacts is an example of federalism, where states retain their sovereignty over the practice of medicine while entering into a contract with other states to provide a national solution or optioned to the licensor.8410 The compact is one of the many tools that is included in this bill that will accomplish the important goals that you have set out for yourselves and we are in support of of that.
The compacts of the concept of compacts are enshrined in the US Constitution and enacting the compact is a crucial positive step towards accomplishing the goals of increasing the number of physicians available to provide care to the patients of the commonwealth of Massachusetts. The compact became operational in April of 2017 and since that time we have processed over 20,000 applications from over 15,000 physicians who have received over 30,000 licenses in our 37 member states and territories. There are four key key aspects. Um There are four key aspects of the compact, The8462 compact benefits your state. Um because it is revenue positive, we've actually had three states and that's not my screen that's that's being shared. Sorry about that.
Um so we've actually had three states that have reduced their licensing fees to the physicians to obtain a license in that state as a result of the increased8487 licensing volume that comes from being part of the compact. It increases physician access while retaining control over the physicians practice of how they practice8495 using that license in your state. The compact number two, the compact benefits your system, your citizens.8503 I'm sorry. It improves access to specialist physicians and it enhances follow up care and the continuation of care once a patient has been treated. And it allows the physician to follow that patient back to their home state if8519 that's appropriate, The compact benefits hospitals especially in rural and underserved areas. It helps reduce physician gaps and it increases the physician workforce that's available to the hospitals to use.
We have examples of this where um and one of the most common that we use in sight Northern Wisconsin is 2 to 4 hours away from the population centers where the majority of the physicians in that state reside. They've had difficulty in those rural and underserved areas in obtaining qualified physicians so that they could extend their hours or even keep the doors open. But there an hour and a half from Minneapolis which is in another state. By using the compact and using our process, they were able to expand hours and expand services offered to the patients in their hospitals and number four and finally the compact and benefits physicians and makes8573 states who have enacted the compact a place where physicians want to work and want to practice because it creates a single online application for the physician to receive a license in multiple states.
It saves them money and it saves them time. Um, in8592 that application process, the compact process is very much um, to use an example like the TSA. Everyone, if you're going to the airport, you have to go through the x ray machines, you have to go through a level of security that happens. But there are two ways to8610 get there. And what the compact does is it creates an expedited way to get to licensure in your state so that they can practice in your state, comply with your Practice of Medicine rules and bring their expertise8623 to your state. But additionally, and just as importantly, it allows the physicians in the commonwealth of Massachusetts to take their expertise around the country and to expand and assist in other areas and that the compact was critical in providing elasticity to our member States during the covid crisis.
Um, we saw um basically a doubling in our applications and a doubling in our licenses issued. So finally the compact is a critical access point for our member states and I thank you for your time and I welcome any questions and I'm also available for any follow up at a later time.
SHOW NON-ESSENTIAL DIALOGUE
Thank you. Thank you. Are there any questions
marshall, seeing none. Thank you so much. Thank you very much. Next is dr kyoto and dr martin.
Yeah,
massachusetts orthopedic Association. Are you on?
Okay.
I see.
Okay. Dr martin. Are you on? We can't hear you if you are.
Hello? Yes I'm dr kyoto. I can speak after DR martin talked.
Oh
SHOW NON-ESSENTIAL DIALOGUE
yeah. So why don't you go ahead and
CHRIS CHIODO BWH - SB 2774 - Okay, madam Chair, Mr Chair thank you very much for your time. Um I'm Chris Chiodo. I'm in charge. I'm an orthopedist in charge of foot and ankle surgery at the Brigham and Woman's Hospital. I know that this bill is comprehensive. I'm just going to speak to podiatry. Um you know, as I urge you to8771 take out the podiatry section of this it expands their scope of practice um into the ankle and that's for two reasons safety and cost um regarding costs. Our executive director of the Mass8788 Ortho Association has checked with the hospital billing departments of the Brigham, the Mass General, the Beth Israel Leahy and we're told that podiatrists are reimbursed at the same rate as orthopedic surgeons.
We also checked with the website, the Massachusetts state website compare care and with each code we put in the reimbursement between our podiatry colleagues in orthopaedics was the same. So we haven't found any evidence to show increased costs. And we actually have written literature which I'll submit. We have five articles that show actual in other states where podiatry has been performed increased costs. With regard to costs that's one thing that patient safety is paramount. Um it's the only scope of practice issue that involves surgery and the vast majority of podiatrists in our state do not have the training, no residency training to do ankle surgery and this. This bill would allow them to operate um halfway up the leg. I'll tell you have been doing foot and ankle surgery for 20 years and I'm more nervous about doing ankle surgery than foot surgery.
It's complex. It's8853 as complex as the hip of the shoulder. And without appropriate training, the podiatrist should not be performing this. You can see myself or anyone in my department or any other hospitals around the area within two weeks. We have plenty of orthopedic surgeons who can handle it in those states where podiatrists are allowed to operate on the ankle. We're now seeing data and results. I have five papers from the literature, um that I can send to you and submit8880 that document that there's increased costs, increased hospital readmissions and increased complications when our colleagues in those states are allowed to do ankle surgery. So, first and foremost, I urge you to oppose the scope of practice expansion for podiatry for podiatric surgery because of patient safety costs is second in my mind.
But, you know, patient safety as a physician, I am more worried more about patient safety cost is second. We have evidence to support that. It can be more expensive. There can be more complications and more readmissions. So I urge you to take out the expansion of this surgical scope of practice issue from the governor's bill. With all due respect. Thank. Thank you for your time. SHOW NON-ESSENTIAL DIALOGUE
Thank you. And you're you're going to be sending along those literature. Yeah. Again, these are these are from the medical literature in those states where they're doing the surgery. Um, you have increased costs and readmissions and complications and there's something about the FTC has said, well this will, this will expand um or reduced costs and we haven't seen that. And so we do have literature. Again, readmissions, costs and complications. Thank you. Thank you very much. You're um,
I don't know where I think. Um, let's see. Dr martin maybe having technical difficulties, but so I think8976 we're going to have to move on. Um, but thank you, thanks for your testimony and look forward to for the written information. Right. Thank thank you very much. Okay, um,
the massachusetts foot and ankle society, are you here? Oh,
Quinn charbonneau and Tyler Silverman,
I would, I'm here and I think Quinn is here as well. I'm dr Tyler Silverman. Okay, high right.
TYLER SILVERMAN - MFAS - SB 2774 - Um chair Friedman, Chair Lawn Members of the committee. Thank you for the opportunity to testify in support of uh this bill, um particularly the section 42 of Senate bill 2774. I'm dr Tyler Silverman. I am the legislative chair of the massachusetts Foot and Ankle Society a nonprofit associated the association that represents proprietors throughout this commonwealth.9036 I have had the privilege of doing my training here in Massachusetts and I've stuck around despite the significant restrictions and scope of practice in this area. A little bit of background as to the scope and to the law the podiatric profession has advanced significantly since the original scope of practice was written in Massachusetts.
Our scope of practice hasn't been updated in 60 years, which9061 is incredibly long, especially when you compare it to other states throughout9066 the country. Unfortunately, Massachusetts is only one of three states whose statute does not reflect that we can perform procedures of the ankle. Um as the Office of Policy analysis for9075 the Federal Trade Commission stated in 2019, and I believe we have provided you with this and we will gladly provide you with this documentation. Again, Massachusetts, uh current podiatric practice law prevents patients from getting the best care possible. Based on the current statute and existing regulatory environment some hospitals allow proprietors to perform ankle surgery while others do not. I actually have differing credentials at different hospitals.
I personally do that because of this unclear legislation that we currently have. The legislation will establish a breadline rule that allows podiatrists to perform ankle surgery in a hospital setting. To be clear, there are safeguards in place. Um, foot and ankle surgeries can only be performed at a hospital. Um and when a surgeon of any specialty, does hospital based surgery, they have to go in front of a9129 credentials committee before any of this can be9131 done. I've actually, I currently hospitals credentials committee so I can tell you that there is9136 a long list of checks and balances outside of the legislature that ensures that only the appropriately credential people9143 can do appropriate procedures um in order to get credentials passed in order to get different skills, you have to prove your training and the hospitals are very good at taking care of it.
This legislation will provide both more robust network podiatrists performing foot and ankle surgery throughout Massachusetts. Basic wait times will be reduced and more direct access to care will become a reality for Massachusetts patients. Um, podiatrists our specialized specialized on foot and ankle surgery. We basically begin on podiatric training as soon as we uh finish college with the four year podiatric medical degree program followed by residency, which is now standardized at three years across the board. This uh training can help us save costs the health system money by diminishing duplicate services and salvaging limbs and preventing amputations. There are multiple studies out there that show that having a podiatrist on a limb salvage team that dealing with patients with multiple medical issues such as diabetes or geriatrics or smoking or alcohol misuse of substances misuse, all of which can cause amputations helps decrease the risk of amputation.
Therefore saving the hospital system and the health care system and the commonwealth lives, limbs and money. Finally, I'd like to highlight the purpose of the updated Podiatric Practice Act is supported by the following organizations American Public Health Association, Foot and Ankle section, the National9232 Medical Association, Podiatric Medical Surgical Surgery section. The Alliance of Wound Care stakeholders, which shows once again the importance of us in saving lives and limbs and the American Podiatric Medical society. In conclusion, chair Lawn and chair Friedman Members of the committee, I respectfully ask that you include the language updating the Podiatric Practice Act, which is Section 42 any health care reform legislation that moves from this committee. This is a reasonable legislation that increased access and affordability. My colleague, Dr. Quinn charbonneau will now address the training and the experience of today's podiatrists. Thank you. SHOW NON-ESSENTIAL DIALOGUE
Thank you.
QUINN CHARBONNEAU - MFAS - SB 2774 - Thanks Doctor Silverman Chair, Friedman Chair, Lawn and members of the committee, Thank you for the opportunity to testify today. My name is Dr. Quinn Charbonneau and I'm a board member of the Massachusetts Foot and Ankle Society. I'm board certified in foot surgery by the9291 American Board of Foot and Ankle surgery and I'm a fellow of the American College of Foot and Ankle surgeons. I work as a podiatric surgeon in Winthrop and I'm the sole provider of podiatric care to geriatric and disabled patients in 24 different long term care facilities throughout Massachusetts. I'm testifying today in strong support of Section 42 of Senate bill 2774.
The education and training to become a podiatric surgeon is extensive. Just like MDs, we complete four years of education, we attend an accredited podiatric medical school and during these four years podiatry students often attend classes alongside traditional medical students. Podiatry9328 education is unique9329 in that it increasingly focuses on the lower extremity and includes ample surgical training. Before we even graduate upon earning a degree as a doctor of9341 podiatric medicine or DPM podiatrist go on to complete a minimum three year residency in a hospital. During these years of residency, podiatrists are required to log a minimum number of clinical encounters and procedures.
This includes hundreds of surgical procedures of the foot and ankle, notably podiatry residents scrub into cases9361 with and are surgically trained by an attending podiatrist or an attending MD Such as an orthopedic, vascular, general or plastic surgeon. The fact is a podiatrist education and practice model has been directly intertwined with their MD and DO colleagues for many years. Already, once trained a podiatrist enters practice and can become board certified and board board qualified and ultimately board certified in foot and ankle surgery. The process of achieving certification in foot and ankle surgery is a long arduous process that involves numerous exams, the logging of all surgical cases and scrutinization of those cases by a committee in a blinded fashion.
Podiatrists are the only surgeons of the lower extremity to go through a certification process specifically for surgery of the foot and ankle. Massachusetts is in trouble because it is one of only three states whose legislation does not explicitly allow podiatrist to perform ankle surgery will continue to lose the most exceptionally trained podiatrist to the other 47 states, which will allow us to practice to the full extent of our training. Massachusetts, Mississippi and Alabama are alone and legislatively living in the past. I'm personally affected by this outdated Podiatry Practice Act. I have achieved board certified status and foot surgery through the certification process I described on the other hand, despite having earned board qualified status in ankle surgery legislation here in massachusetts prevents me from achieving board certified status in ankle surgery.
My commitment to caring for the people of this commonwealth forces me to compromise so much of what I have worked for. Without this legislation, the most highly trained and qualified podiatrist are heavily incentivized to leave Massachusetts and I'm not alone. In a recent survey from the seven podiatric residency programs in Massachusetts found that nearly 60% of newly licensed podiatrists decided to leave our state specifically because of the scope law. SHOW NON-ESSENTIAL DIALOGUE
I'm going to ask you to...
CHARBONNEAU - the final frontier Friedman Members of the committee, I respectfully ask9497 that you include the language updating the Podiatric Practice Act Section 42 in any health care reform legislation that moves from this committee. This is reasonable legislation that will increase access, reduce emergency room9509 visits, improve affordability and retain highly trained podiatrists. Help us protect the most vulnerable patients of the commonwealth. Thank you again for allowing me to testify today. SHOW NON-ESSENTIAL DIALOGUE
Thank you. Thanks for your testimony and we we will definitely be9545 looking at this. Um
Okay. Next is
Catherine polio. Hello
Catherine
I.
CATHERINE PELULLO - MGHA - SB 2774 - Okay, good afternoon Chairwoman Friedman, Chairman Lawn and this Health Committee on financing. My name is Katherine Pelullo and I want to thank you on behalf of the Massachusetts General Hygienists Association for the opportunity to testify at today's hearing. MGHA and our hygienists work every day throughout the commonwealth to improve the public's oral and overall health and promote an increase awareness of the health and class benefits of dental care. I'm here in support of Section 51 B of the of the governor's bill which would establish general therapists in the commonwealth. This is a move that already has broad support in both chambers and rather than providing statistics in my testimony today, which will be included in the submitted written testimony.
I would like to just give you a couple of examples of how dental therapy could improve access to oral health care for the commonwealth resident. The first example includes an elderly woman. Imagine your woman, your mother is in her 90s homebound and has received comprehensive oral health care throughout her entire life. She is experiencing pain but can no longer be transported to a dental office for treatment. This is a call that I have personally received from the woman's daughter who lived out of state a couple of years before the pandemic. As much as I tried to search and research all options available to her, I was unable to find a practitioner who would be able to go to her home to provide dental care for this aging and woman who was in declining health.
A dental therapist could have made a home visit, assess the patient and provided treatment within the scope of of a dental therapy practice. And I think the reason that she contacted me was because for 39 years of my dental hygiene career, I have worked primarily. I worked with children and adults with intellectual and other types of abuse of disabilities and community based settings. So my name has kind of been out there as a possible resource. The second example that I would like to provide you with is imagine your child participates in a school based preventive oral health program. You receive a notification from the school hygienist or the school nurse that your child needs to schedule an examination with a dentist because the hygienist noticed areas of possible decay in the child's mouth.
You work full time as a parent you work full time and a job that does not pay a lot of money, perhaps 12 to $15 per hour and your employer does not allow you to take time off from your job to9746 take your child to the dentist. What do you do? This is a dilemma that many families face throughout the commonwealth. And it's also a a situation that hygienist who work in these settings see on at least a weekly if not a daily basis. So on follow up visits to a school, the dental hygienist in saying this. But these Children noticed that those areas of decay that may have been small when they were first observed appeared to be gaining larger in some cases result in pain and in emergency care. If there were dental therapy was allowed in Massachusetts, the dental therapists would be visiting these schools treating these children and taking care, you know, treating the cavities um up to the limit of the dental therapy license.
Um these are two examples and I know that our time is very brief today. I will be submitting written testimony with lots of statistics. Um this isn't new. It's been in existence for over 100 years and other parts of the country and around 10 years in a number of states within the United States of America. So I thank you, Chairwoman Friedman and chairman Lawn for the opportunity to testify on behalf of increasing9830 access to oral health care for the commonwealth residents. Thank you very much.
FRIEDMAN - Thank you Catherine. Just one clarification. You you said section 51 but you're including 51, 51 and a half and 51 B?
PELULLO - Yes, 51 B. Yes, thank you. SHOW NON-ESSENTIAL DIALOGUE
Okay, thank you. Um Any questions from the committee? I don't see any. Thanks so much for your time. Thank you. Um Next we have the massachusetts excuse me, massachusetts Association of physician assistants, josh josh Merson, Coulter, Chernow and Duncan, W
josh cole or Duncan. Are you here?
Okay?
Moving on to
Catherine, Rush first. Emily anesta Tiffany vessel and an Whitman.
Are you all here some of you here?
I don't see anybody.
I'm just checking to see if you're on.
Okay. Um That is uh
9932 Hi9932 who
are you Duncan?
You are on mute.
Sorry, Chairman Friedman and members of the committee. It's a busy day at the emergency department so I appreciate you waiting.
DUNCAN DAVIAU - MAPA - SB 2774 - Um So I'm Duncan Daviau I am the President elect of the Massachusetts Association of Physician Assistance. Um and I want to talk today about the legislation before us and some issues and regarding S2774. This legislation has written with conflict with and be a step back from the current executive order issued by Governor Baker on PA practice. The bill is written is confusing um as it adds an option for PA physician collaboration without any clear definition or guidance.10002 Um I'd like to urge the committee to either replace the PA the10010 provisions regarding PA practice um with language of the bill already before10016 this committee S40 an act relative to removing barriers to care for physicians uh physician assistance or simply strike the PA10024 language from S 2774 and move forward with S740.
PAs are10028 licensed medical providers10029 who practice medicine in every specialty in setting PAs obtain a minimum of a10035 master's degree10036 and there's also a growing number of PAs who are earning doctoral degrees. Each PA10044 is trained and educated to expand access to care through team based practice. The typical PA students has completed a bachelors degree prerequisite coursework and commonly10052 more than 3000 hours of10055 direct patient encounters before entering a PA program coming out, PAs have a 2000 hours worth of didactic10061 medical training. In 2000 hours of clinical practice in different medical and surgical specialties, Governor10067 Baker issued a public health emergency order in January 2022 which built on the original order started during the pandemic heyday. It allowed PAs to practice without10078 filing a super visit supervising physician, both with the commonwealth and10083 at the practice level.
It allowed PAs to expand their10087 practice and moving to areas of most need, most notably covid units, covid testing sites and eventually vaccination centers. As10096 a result result of this, PAs were able10099 to practice to their true potential and there10103 was no negative consequences.10104 Under S 2774 PAs would lose that workforce flexibility and worse in the commonwealth would lose the access to expanded care that previously we had. S740 would permanently amend massachusetts. General laws, remove the10121 requirement that a pa in the commonwealth file supervising physician with10127 the10127 state. It is important to10129 note that while it removed the supervision requirements, it will10135 still allow an employer to require any degree of collaboration or supervision it desires with the PA and with10142 another health care provider without the unnecessary and burdensome paperwork requirements that have slowed access to care and flexibilities for PAs.
This bill would make PAs legally responsible for the care they provide. These changes would allow PAs to10155 continue to provide the highest level of care to their patients. Both10160 they're both during and after the pandemic map of10164 respectfully request that the community incorporate the language of S740 the intent of the10169 recent executive orders into10170 this undergo ongoing bill.10171 Thank you guys. SHOW NON-ESSENTIAL DIALOGUE
thank you and10173 uh get back to work. We need you10176 so yes, thank10177 you. Chairman Friedman I really appreciate your10179 help and I'm sorry for being10181 a few minutes10182 later. It's just a crazy10184 day here in the emergency10187 department. We don't argue with people who are in emergency rooms taking care of10193 patients. So go10194 back. Thank10195 you. Thank you. Thank you for your10197 time you to. Okay and last10198 I think we have Catherine. Are you on? Yes you are. I am10202 sorry some really crazy10203 Day Um
CATHERINE RUSHFORD - SB 2774 - Thank you. Chairman Friedman and10206 law and honourable members of the Joint Committee on10208 health care financing. Thank you for the opportunity to submit testimony on the governor's health care bill and in10218 support of improving access to midwifery service and birth centers in10223 massachusetts, I respectfully request on behalf of the over 500 certified nurse midwives practicing in the commonwealth that the Legislature add and include equal reimbursement for CNMs on any10232 omnibus health care10233 bill that you10234 put forward. My name is Catherine Rushford. I'm a certified nurse midwife, also known as CNM And Legislative co chair of the Massachusetts Affiliate of the American College of Nurse10246 Midwives.
I spent10247 the last decade10248 in clinical care, including the10250 last two years working through the covid 19 pandemic. The evidence is10253 overwhelming that midwives improve health outcomes while reducing health care costs10256 and this is particularly10257 for black and brown birthing people.10259 In a 2021 report from the Mass Health Policy Commission, they found that midwifery care10263 lowers the risk of cesarean section and10267 results incost savings of over $50010270 per maternity episode.10271 In a 2018 study10272 of Medicaid recipients, they concluded that midwifery care and birth10276 centers resulted in lower rates of preterm birth, low birth weight babies, lower10280 caesarean section rates and over $2000 in savings per birth.
But currently Massachusetts is in the minority of US states and it is the only state in10291 New England that has no requirement10293 for insurance companies10294 to equitably reimburse CNMs for their care. The result of this inequity is10300 that hospital systems are reluctant to10303 offer or expand midwifery10304 services and clinical sites10305 with midwives, including many10306 community health centers have less10307 resources to provide vital care. H3881 an act to increase access to nurse midwifery services filed by Representative10314 Khan and reported favorably by the Joint Committee on Financial Services. And currently10319 sitting before this committee would address this by insurance ensuring10323 CNMs receive equal10324 reimbursement to physicians for providing the same medical services.
Equal reimbursement for midwifery care is also essential to the growth of birth10333 centers in the commonwealth. Despite the incredible outcomes10336 of birth centers, Massachusetts currently only has one fully functioning birth center. I10342 therefore want to ask also for support for Representative Liz Miranda's proposed budget line item allocating $500,000 to10349 community led birth centers. Covid 19 laid bare10352 the health inequities that have existed for decades. But now we have an opportunity to re evaluate10359 our systems and implement10360 high quality cost effective care. The lives and well being10364 of tens10365 of thousands of pregnant people and their babies10370 depend on it. It10371 is for all the above reasons I speak in strong support of H3881 and the10376 act to increase health nurse midwifery services and10379 the budget10380 line item for community10381 led birth centers. Thank you.
FRIEDMAN - Thank you. So are you asking that the committee include that in this10386 bill?
RUSHFORD - Yes. So my understanding10388 is that right now there is nothing in10391 this bill around reproductive10392 health and midwifery care and10394 maternity care and that this10395 actually would be an opportunity to10400 move10400 this bill. This this part of10402 maternity care forward. SHOW NON-ESSENTIAL DIALOGUE
Okay. I got it. I understand. Thank you. Thanks so much. Just full10408 disclosure I delivered with midwives and
okay. Um, any questions.
No questions. Okay. Thank you. Um All10413 right. Um let me10414 just make sure there's nothing really. Uh and I think we have reached the end10419 of10420 the10421
of our hearing and um I asked for10424 a motion to10425 adjourn. So moved.
I hear a second. All those in favor Ayers ye pose.10438 No,10438 the ayes have it. And10441 this hearing is now adjourned. Thank you10445 everybody.
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