Good afternoon, and welcome. I'm glad to see so many stakeholders joining us today for NCQA's fireside chat. For those that may not have joined us for previous fireside chats, this event is designed to surface honest perspectives, ones that go beyond presentations and how our partners are working together for a better health care system. We're pleased to bring together leaders at the forefront of transforming health care quality, delivery, and accountability for a conversation on how states are navigating today's evolving challenges and opportunities to create a more person centered system of care. So let's get started. Next slide. First, we'll review some logistics. We will have time towards the end of the discussion for audience questions. Please enter your questions in the Q and A function in Zoom. We will get to as many questions as we can. For those joining the conversation on LinkedIn, jump into the conversation using NCQAFireside on social media, and be sure to tag us in your posts at NCQA. We will also be sending a recording of the event and any supporting materials to all who registered and posting a summary on our blog. Next slide. Now I have the distinct pleasure of introducing our moderator for today's fireside chat. Tom Curtis is NCQA's director of state affairs, where he manages a multi team to promote NCQA programs, measures, and services to state executive and legislative branches. Prior to joining NCQA, Tom led health equity, quality improvement, behavioral health, and public health initiatives in Michigan as the director of quality for Medicaid managed care. So without further ado, Tom? Thank you very much, Amy, and good afternoon or good morning, depending on where you're joining us from. Thank you for spending some time with us, and we guarantee it's gonna be a good use of your time today. When we do these fireside chats, we we wanna accomplish a few things. We wanna find somebody who is very interesting and brings a unique perspective to a certain, aspect of health care reform work. And we do that because we want to offer them up to the audience to ask questions. So we would encourage you at any time during the conversation or even right now, if you've already looked at doctor Lee Robinson's file to start putting those questions in, and we're gonna try to get to them. The other reason we we look for someone is to ensure that what NCQA is trying to support in health care delivery, is sort of expanded upon outside of what NCQA does, and that we bring somebody in who can provide that broader lens and perspective beyond what NCQA is offering. And we think we can do that with our guest today, doctor Lee Robinson. Doctor Lee Robinson, which I'll, I'll just call you Lee from now on. Like, you asked me to before we got here, but it just felt a little odd, to not start that way, is the associate chief for behavioral health at MassHealth, where he oversees behavioral health policy development and implementation for Massachusetts Medicaid and their children's health insurance program or CHIP. Doctor Robinson also continues to practice part time as a psychiatrist. And the rest of the bio is talking about your time at Harvard, Brown University, Washington University in Saint Louis, University of Cincinnati, Columbia University in Cambridge. So before we even get into, some sort of policy detail conversations, Lee, I that's phenomenal to read a bio and and to hear somebody's journey kind of going all over the place like that. And just curious if you could start for the audience, what's your most memorable, stop along the way in your journey that that has brought you here today? Yeah. Thank you so much, Tom. Very happy to be here, a big fan of the NCQA. And not sure what it says about me if the, first thing that comes to my mind is, all of the great, food in Cincinnati, Ohio. And I think I was I was thinking about this, you know, the time in each of those places is very colored by my experience and what I was doing there. And so, of course, I did med school in Cincinnati. And so, I know all about which bakeries are open twenty four hours, and I know all about which Skyline Chili's are open, all hours and, the Grater's ice cream. And so, not sure what it says if my head is there at this moment, but that's probably the most memorable is, all of the great food and all of the great friends that I, spent eating it with. That that says a lot of good stuff, I would say, and makes me hungry even though I just ate lunch. I want to now move into a question that's getting at your self interest because it could be something that inspires the audience. So my next question is why behavioral health? Why why clinical care, and why psychiatry? What about that is fulfilling for you? Yeah. Yeah. I mean, I think that, talking about, Buscans bakery and, Grater's ice cream, it brings me back to med school. You know, I always knew I wanted to be a a physician. I wanted to help people that, you know, has always been very, very important to me. And I thought that I was gonna go into pediatrics. And, you know, my my first pediatrics rotation, you know, I was working on an adolescent unit. And so, for an adolescent to be hospitalized in a hospital for for medical reasons, behavioral health is typically not that far away. You know? We would we would treat adolescents who, you know, unfortunately had attempted suicide or were dealing with, a severe eating disorder or were dealing with some very, very serious medical conditions. You know? It takes a lot to bring an an adolescent down to the point of needing medical hospitalization. And so, you know, we're talking about cancers or kind of chronic genetic illness. And the time that I spent, during that rotation was mostly spent behind a computer and looking at labs and, you know, following numbers and so on and so forth. And I felt like, any of the the conversations about the elephant in the room, you know, the elephant that was kind of very much, in in every single family that I interacted with in in that space was always kind of an afterthought. And my next rotation was adolescent, psychiatry, and, the whole purpose and goal of that rotation was to talk about the elephant in the room. And, you know, going in and actually getting to talk about what these, teenagers are struggling with and talking with their families was just life changing. And, you know, I don't necessarily come from a a background of, you know, behavioral health professionals or anything like that. And so it was it was the furthest thing, honestly, from my radar, but, definitely one of those moments of, oh, I can see myself doing this for the rest of my life. And, you know, someone who is a is a proud past camp counselor, you know, it really seemed to fit with helping, you know, helping people feel comfortable and helping them live the the life that they wanted to live to to live. And so that kind of very rapidly changed my trajectory, and I have not looked back since. So I wanna get into the Massachusetts road map, but not quite yet. So the step from they've shared, kinda why you got into behavioral health and psychiatry. What I wanna, the audience to hear about next is how does that clinical perspective or how has that clinical perspective, played out in your in your role as, like, a policy setter and a policymaker in MassHealth. So what's what's been that sort of, the advantages and the impacts and the strengths that you've seen translate into this role that you're in? Yeah. No. Thank you for that question. And I think that's, you know, also, I I don't know if I'm exactly, typical in that. I never expected to work, you know, for a Medicaid organization or work for a payer or work for a government. I fully intended on just working as a clinician. And I still do, work clinically a few hours, each week, and it is more than enough to see that while we have made some progress, all of the problems that, really forced me into working, for the state are still very much alive and present and, still plenty of work to be done. And I think to sum up the the problems that really kind of pushed my career to its current place in working for a Medicaid organization is the realization that the system is just fundamentally misaligned, in that the the system, the health care system at large, but inclusive of the behavioral health system, it is it is aligned with maximization of billable, you know, units of service, and it's not aligned with actually improving the health and well-being and and health outcomes of, our our members, our patients, and and the communities in which we live. And I think that to to work as a clinician knowing that and experiencing that day in, day out is just it's it's kind of morally exhausting. And it's it's exhausting also, and it's very just frustrating because it feels like we have all of the right ingredients. You know, I I think that we have, you know, an army of passionate clinicians, and we certainly have more than enough money in our health care system that we are throwing at the problem. And if we could actually just align those things in in the interest of our patients and the interest of of our members, achieving, outcomes, I think that we fundamentally have all of what it takes to have an amazing health care system. But to work in that day in and day out and to see how far we are from that reality is just is just really hard. And for me, it's it's it's an existential concern for the the sustainability of our health care system and particularly for for behavioral health. You know, if we continue on this path, you know, we're we're gonna be in some even rougher shape than we are now. And I think that, you know, our health care system is really confronting some some strong realities right now, and I think that this is all part of the same issue is that we need to really kind of change the trajectory and and align the incentives, you know, of the the systems and the providers with with the patients that we're working with. Thank you so much for that. I I simultaneously like and also I'm very sad in the in the use of moral morally exhausting. And, I mean, it makes sense, and it's also just it's it's difficult to accept, right, and acknowledge, but it's the truth. Yeah. I think it's a good segue then to the Massachusetts behavioral health road map. So I'm wondering if you would be willing to just at a you know, the thirty second clip of what it is. And that but but what I'd really like to hear about is, you know, what what part of it are you just most excited about? Or do you like, if you get a meeting for this initiative in the road map, you're like, heck yeah. I wish I could just do that all day. Yeah. So talk about, you know, your your your favorite part or your most exciting part. Yeah. Yeah. So the the road map for behavioral health reform in Massachusetts, is a multiyear, endeavor that, kind of formally launched in twenty twenty three, but had a lot of work in the years leading up to it. And a lot of the work, in the years leading up to it included, you know, state leaders going across the state talking to as many different people as they can to find out what, was broken about the behavioral health system to know how to kind of steer things in a better direction. And after hearing from over seven hundred individuals throughout that process, the feedback was actually pretty similar and was pretty consistent, and it all comes down to access, that, individuals were not able to access behavioral health care, period. But I think, additionally, they were not able to access, behavioral health care that was accepted by their insurance, that was geographically accessible, that was flexible to their life's demands, or that integrated mental health and SUD, or substance use disorder, or that, integrated the the appropriate cultural and linguistic, capabilities that that meet met their needs. And, you know, I think those of us working clinically at the time were were not surprised to hear this feedback. I think, like, you know, like I referenced before, this is what we, you know, experienced day in, day out that when you work within a health system or a clinic, which was most of the clinics that I've ever worked in, that are, you know, optimized to to maximize billable units, that's very much antithetical to addressing population health needs. And to a large extent, there's actually a disincentive to provide timely, flexible access, particularly for individuals with complex presentations. If you're trying to maximize billable units, you want, you know, people who are gonna show up on time and who are not gonna have, you know, complex needs that are gonna, you know, derail a schedule for for the day. Right. You can get them in and out. Yeah. You wanna get them in and out, and and there's actually, you know, in some ways, perverse dis disincentive to actually get them graduated from treatment and and go on to to other parts of their life. And so, you know, in this setting, the the only reliable front door for someone experiencing a crisis is the emergency room. And so, you know, in the years leading up to the our road map launch, you know, we had thousands of people in Massachusetts who were waiting in emergency rooms for behavioral health care. And, you know, that ED boarding crisis, Massachusetts was certainly not the only state to to deal with that, but it was certainly worse than it's ever been in our state. And so through all of that planning, you know, the road map has many different elements, but, you know, two of the the most impactful, of the initiatives is one is a a network of a brand new provider type. And so community behavioral health centers or what we call CBHCs are fundamentally a different clinic than what exists, you know, outside of this space in that instead of having, you know, a very narrow front door or even oftentimes a locked front door, CBHCs are twenty four seven, three sixty five. Anyone can walk in. They're brick and mortar front doors in every, community in Massachusetts. And so we opened up thirty one of these CBHCs. And while Massachusetts is not a CCBHC demonstration state, our CBHCs have a lot of the same components, though they also each have, youth and adult mobile crisis intervention teams that can go into the community and meet with folks as well as access to twenty four hour diversionary beds for people who, need to be somewhere that's monitored but don't need to be in kind of a locked hospital setting. And then if those are the brick and mortar front doors, the other major component of our road map was the behavioral health helpline, which is a twenty four seven, three sixty five, payer agnostic, virtual front door for people to, access care. And this is more than just calling and getting a list of phone numbers that many of them probably don't even work. This is actually getting a live triage from a clinician, and oftentimes a warm handoff in which you are staying on the phone while they connect with a local CBHC, and you're talking with a clinician getting yourself an appointment for the next day. And so, you know, that the fundamentally, the goal of the road map was to change the dynamic in the system away from one that was very much built, for a purpose that was not necessarily population focused and really create a a new, clinical model that is, open, flexible, accessible for for folks with behavioral health issues. So that, thank you for that because it has just actually sparked our first question. And I'm gonna just kinda throw it out there live because I think it's relevant for what we just talked about. Emma writes, would love to hear a discussion of the pros and cons of pursuing CCBHCs outside of the demonstration. So, maybe the way to frame this for you is what what led to Massachusetts going in the direction of their own CBHC model Yeah. And and choosing first of all, did you choose to sort of not pursue CCBHCs and stay outside of the demonstration, or do you also have CCBHCs? Or and what's the what are you noticing or maybe the pros and cons of of the current approach, compared to pursuing the federal model and the federal corresponding federal funds? Yeah. Yeah. So it's a great question, and and I I'll kind of do a cop out to start in that, you know, I've been with MassHealth for for four and a half years, and so the decision to to kind of chart our own path, was was not something that I was a part of. And I do think that there was a lot of consideration, about whether to participate in the CCBHC demonstration. And I I think that it's it's not through any, like, explicit, you know, negatives part of that process. I think it just like, the the the unique politics and the unique kind of constellation of of factors going on at the time led Massachusetts to pursue this path. I will say that, you know, I think that the the cons of participating outside the demonstration is that, I think what what SAMHSA and the the national council have done to support states, who are considering going through the demonstration and are participating through the demonstration has just been really inspiring. I think that it's it's just really amazing work that that those organizations are doing, and I I think that the support they're providing is is really making huge difference. And part of me is jealous, you know, of the states that get to participate in that process with those with those entities. I also think that, you know, there's a enhanced federal match for those states that are participating in the demonstration, which we unfortunately are not, getting in in our work. And I think that a lot of the the components of the CCBHC model, you know, there's just been so many different examples across the states, to to draw from and and to work with that it's it's just a really great community. And so for Massachusetts, we did not participate in that demonstration, and so we didn't necessarily get to benefit from all of those components. But I think that what we did get the benefit from is that, you know, what we ended up building really does feel unique to Massachusetts. And, you know, while the states that are in the demonstration and doing CC BHCs, you know, a core component of that approach is to assess the needs of the communities and align with the needs of the community. So it's not to say that they are not doing, the model that that's, unique to their state. But I think that, you know, because our model was just completely homegrown, it really relied on all of the different components of the system to come together and agree on one model, and that includes, you know, all of our provider groups, all of our our, advocacy groups, all of our patient advocacy groups, family advocacy groups, and, and and all of our payers in the ecosystem that we have in our state. And so it really did was a kind of a magical moment in which all of those parties came together and agreed on this constellation of services and agreed on the way that it would be structured. And so it really does feel like it's, you know, made for for for our needs. I think that also because of that, and because we're not participating in demonstration, we do have a little bit more flexibility then as it relates to how we do our payment model and also how we set up our, you know, quality incentive programs and things like that. There are elements of the CCBHC model that are relatively prescribed, such as the payment model and the and the quality, incentive panel of of, measures. And so those are two areas that we've been able to kind of, go kind of a in a unique path, but, not to say that one process is better than the other. Yeah. That makes a lot of sense. Stakeholders who local stakeholders in particular who get the chance to collaboratively design what they would propose to participate in end up feeling like they own or or, you know, have to do their role that they just sort of advocated for, versus a sort of prescribed model coming down to them to kinda make them. Yeah. I can see that. You've sort of got into this. I we got another question. And you sort of got into this. But Rachel asks, what authority are you utilizing under CMS to fund the model, and what has been the impact on state funding levels? So, yeah, are you using federal match? Is there authority that's allowing you to do that? How is it impacting your g use of g f, that kind of thing? Yeah. So, we do have Medicaid authority for all of the components of our model, and the components are a mixture of state plan authority and, eleven fifteen authority. And so we have eleven fifteen authority for for our diversionary beds, the the community crisis stabilization beds that I referenced that all of the CBHCs have access to. And then we have state plan authority for clinic based services and for our mobile crisis service. And so we, get federal match in the same way that any other, Medicaid authorized service gets federal match. And so outside of general funds supporting the state share, there's really no other kind of expenditure of general funds to support the model. And, you know, one other unique element as far as all of the entities coming together is, you know, we we actually it was a priority for for our model to be payer agnostic, much like the CCBHC demonstration. And so, we actually have a, legislatively created trust fund that helps defray the costs for, any members who are underinsured, at the time of seeking care at a CBHC. And so, a trust fund that that is kind of created by our legislature and is is is supported through various types of assessments, is, again, a unique Massachusetts approach to a payer agnostic process. And it's, again, something that helps, you know, defray our general fund ex exposure. If I were to try to Google for that trust fund, what what could I Google to to find out more? Yeah. And I'm happy to to send folks information. It's Okay. Internally, we call it botchy. I'm not sure that that that totally caught on, but it's the the behavioral health access and crisis intervention trust fund. Trust fund. Okay. Yeah. So b h a c I, trust fund is is, the model. And for the state audience, you gotta go make your own trust fund, but at least it might give you some ideas. You can't tap into Massachusetts. Yeah. You can bar you can borrow our acronym if you want. But There you go. There you go. Alright. If good questions. Please keep them coming. I want to, we could spend a long time on this next one, but what I wanna do is come back to what you've said a couple times and what you what what we I agree. We agree is the morally exhausting part of health care, in particular, health. And that is this focus on volume versus population health and value, which probably steers systems away from prioritizing racial ethnic disparities or disparities based on sexual orientation or, you know, other types of unjust, differences in the provision of care. So I want you to kinda go wherever you want with this, but, like okay. So how do we how do we start getting at that? The part that you were like, this is not okay. I'm gonna go try to find some power to address it. Right? And and finding a place in Medicaid, not a bad idea to to to take a shot at. How do we start how do we start going about that? And maybe at some point in our conversation, we can talk about measurement and the role of measurement in that, and what needs to happen in the context of measurement to really help you and others like you trying to go move in the direction of value based care and behavioral health. Yeah. So I I'll stop, but hopefully that's enough to get you get a reaction. Yeah. Yeah. I mean, I think that, you'll I'll try to keep myself from getting too much lodged on the soapbox, and so you'll have to kinda push me off of it if if I get too wordy. But I think that, you know, starting from the end there, I think the the holy grail would be, you know, a system in which we're paying for health care improvement, you know, and that we're paying for, you know, providers improving the health outcomes of the individuals that they see. And, you know, having that kind of laser focus across our providers, across our payers would, you know, be the the the holy grail of of of using all of our resources and using all of the ingredients in the best way possible. I think, unfortunately, we're not there yet for obvious reasons. And I think, you know, one of the big ones and and one of the reasons why I'm a huge fan of NCQA and and, you know, wanna support NCQA in in any and all the ways is is that we just need, you know, more and better outcome measures. And I think that, you know, I know NCQA is really trying to move the needle in all of the right ways. But, ultimately, I think that we need to, you know, work our way past, you know, process measures, past kind of process outcome measures. And, eventually, you know, I'd love to to, you know, still be working, you know, clinically at a time when we actually had something like, you know, functional outcome number, functional outcome, measures. You know, you think about other fields in in health care where, you know, instead of, you know, focused on the specific, you know, hip surgery, you actually are paying for a return to functional status of someone who, you know, has hip hip osteoarthritis. And and, you know, you can think of many different examples in which if you focus on, like, the actual improvement of the functional outcomes and you can get everyone mobilized to improve those outcomes, it's gonna be best thing for patients, best thing for providers, and best thing for for state and state budgets, honestly. And so I think that, you know, until we get to a place where we have those measures, I think, you know, one area that we've really been focused on at Massachusetts is how do we, you know, change the way we pay for things so that they are objectively less kind of granular widget based payment models, and more, you know, either global payment models or bundled payments so that it's really either at the population level or at the, you know, population treatment level. And so I think the CBHCs are actually a good example in that, you know, our CBHCs are paid with a daily bundle. And no matter what type of treatment is provided to no matter what type of member who who presents or individual who presents, that, clinic gets a lump sum. And it's really changing the way we think about folks coming into the clinic, and it really changes the way that we think about what we do when they kind of come into the clinic because we're no longer, you know, trying to maximize the specific CPT codes that have the largest margin. And instead, we're actually thinking creatively about, you know, what does this person need and what would be the best way and and the right team to provide that care. And I think fundamentally, health care is a team sport, and we just have never paid for it as a as a team payment. And so I think one of the things we're trying to do is move the needle in paying for team based care because I think that also gets everyone, you know, operating to the type of top of their their skill set and the top of their their training, and it helps us really think creatively about, what workforce is doing, what tasks, and really maximizing the resources that we have. And so I can go on and on, but I think that, you know, if the holy grail is paying for outcomes, you know, how do we start by at least paying for team based care and allowing some flexibility and autonomy in that patient clinician relationship. Yeah. As you're so as you were talking, I'm thinking, alright. Maybe a little bit of a chicken and an egg issue to a certain system wide anyways because do we create and that's the royal we. Right? It's not necessarily NCQA. But do we create outcomes measures even though we all know the system isn't still isn't paid for that? Or do we wait for the payment to be prepared to pay for outcomes? And then we ins right? Like but what you're saying what you ended up saying was there are already instances of payment moving in the direct this direction. So let's capitalize those instances within the system. Maybe it's not system wide yet, but there are instances within the system that we can leverage to start promoting and using outcomes based measures where it would make sense for all of the actors in the system to go to move forward as a team. That's that's kind of what you're Yeah. I would to get there. Right? Yeah. I think it's both and. I think I think it's I think it's it's both at the same time. And and, you know, I'll I'll give one example from my past clinical life. You know, in training you know? So I was actually a training director in a in a previous life, and so we I trained child psychiatry fellows. And every day, these these trainees are talking with many, many different supervisors and bosses about, like, learning different treatments and how to help their patients feel better. And, it's just like you're immersed in this. Like, the entire focus is helping learn how to help people get better. And then when you enter the workforce, no boss will ever ask you if your patients are getting better. They will ask you, though, to complete your notes on time and to see more patients with less time and and so on and so forth. The one and only time in my entire clinical career where I had a, a boss who actually asked about a patient outcome was during a very brief time when I was working as an integrated, psychiatrist in a primary care office, and we were suddenly now going to be held accountable to, depression response and remission as a quality outcome measure. And that clinic mobilized in a way that I did not think was at all possible, and we overnight started actually tracking, you know, how our patients were doing, and we actually developed the processes to make sure they were getting better and figuring out what was going wrong if they weren't getting better. And then, you know, six months later, something happened where I think the health system realized that, the margins were not, you know, not enough for our hospital to to care about it in the way that, that that we felt we should. And so then it kinda dropped out of favor, and then we returned to functionally a group practice model. But I think that so the the the factors just weren't, like, right at that time, but it just proved to me that, like, we can do this, and we can do it, like, at the turn of a, you know, turn of a dime if we are allowed to, and if we can. And so while, you know, the certain circumstances weren't, you know, aligned at that time, they are getting more and more and more aligned. And so the more that we can kind of make sure that the the environment is primed and ripe for that type of, aligned work, I think, the better. So we've talked about how there there is a vital need for outcome based measures. We've talked about the opportunity that some examples of team based payment or outcome based payment, we're getting there. Right? Yeah. So my next question is, so going down a level into the clinic, or the or the provider system, the the term behavioral health integration, obviously, is used all of the time. Yep. It can mean a lot of different things. If if you wanted the audience to walk away with some insight or some, constructive idea of what behavioral health integration should mean to them, what would that be? And then in your perspective, is it is it SUD and behavioral health integration that's more important or chronic disease and behavioral health? Or right? Like, integration relative to what really should be maybe maybe the first priority or the what do they call it? The lowest hanging fruit Yeah. Relatively, obviously. But so I'll stop and see what you got. Yeah. I mean, I think that, behavioral health integration, however it is defined, should be pursued in all of the ways that that it can be pursued. But because fundamentally it is doing something new that and changing the culture, it it really does need, buy in for it to to be successful and and not only successful, but sustainable. You know, I I like like I mentioned before, number of years in my clinical past were spent in an integrated role working with primary care, working in primary care clinics. And, there were primary care providers who were fully on board with an integrated psychiatrist being in their office, and they were fully on board for how to think flexibly and how to kind of, work in this integrated space. And then there were some who were very much not so and very much very skeptical of what this would be. And, fundamentally, you know, when integrated care works best, it's it's a it's a, clinical model built on trust. And if a primary care provider does not trust the behavioral health staff that are in their office, and if the behavioral health provider does not trust the primary care team and trust, you know, involves, you know, while it's shared benefit, it's also some shared sacrifice in that there's gonna be times where the behavioral health clinician will take on some of the work that the primary care provider does not want to do. But at the same time, the the the primary care team needs to take on an increasing amount of behavioral health treatment so that the behavioral health team has access for the next person that they send to them. And so all of this is to say, I think that it's such a relationship that's based on trust, and it's essential that it's based on trust that it really needs to be whatever model or whatever the issue is that is the most salience to those providers in that practice. And so if that is a practice that, you know, for that moment in time is really, you know, struggling to figure out how to support a whole host of people with chronic medical illness and comorbid, you know, behavioral health conditions, then that that should be the focus. If it's a clinic that is treating a high pop you know, population of comorbid substance use and mental health, that should be the the focus. I think it really does need to be, you know, whatever will have the most buy in from the people on the ground and from the leadership to support, that's gonna be the most successful. Because I think that, otherwise, you know, this pretty much any clinical model that is forced onto providers is doomed to fail, but this one in particular is is particularly prone to failure just because of how much it relies on trust. So you are getting into, something really important, that sometimes I notice is just not dug into very often, when when there are conversations universally about behavioral health integration or practice transformation or value based care model adoption or those sorts of things. The fact that it takes time and is based on relationships and trust. I mean, my so when I'm whenever I'm working with somebody and if it's brand new working relationship, there are bumps in the road. And there I mean, we've gotta figure out who we each of us are and how we operate, how we communicate, what's important to to one another, that sort of things. And so you're saying, that is very true in all of these different partnerships in the team. That is also true, and it takes time and long term commitment and culture change. It's not just a matter of a behavior, you know, a simple behavior change. Right? That's kind of what you're Yeah. What you're getting at. Do you think that's well understood, when when we broadly are when we generally are talking about value based care and outcomes focused and and care integration. And and if not, what's the impact of that if we're not really paying attention to that vital piece of what what we claim is really important and we're trying to get at. We the royalty here, of course. Yeah. No. I know all too well, what it looks like when we undervalue or underappreciate the the culture change element. And not that all roads lead back to the road map, but that's that's the one that's most salient right now when when when you ask that question is, you know, the the the creation of these CBHCs, it's it's a it was a brand new way of providing care in the sense that, you know, you're asking behavioral health clinicians who are used to having full control over their schedule and full control over their calendar minute by minute to basically have wide open front doors, and have be be asked to operate with full flexibility on whoever walks in and whatever they need. And, I think that it was very, very easy to think that, oh, you know, the network has launched, you know, mission accomplished. We've we've solved behavioral health. And, I think, you know, one thing that I acutely experience, and I would advise other states, you know, considering big big, you know, seismic changes, is to really manage the expectations that this is a culture change. Like, this is while while there's this is a new provider type and a new payment model and all that, this is also a gigantic culture change. And so you're not gonna see everything get better after six months or twelve months. It's gonna take years. And, I think the last time I looked at the literature, it said, you know, a new evidence based model takes fifteen years to to permeate practice. And so, you know, we're trying to make that adoption curve go as quickly as possible, but but it's still an adoption curve, and culture change is hard. And there is a real strong, you know, pull of gravity to the status quo. And I think that, you know, in with the launch of the CBHCs, you know, we see that across the board. You know, we see that from the actual members in the communities, you know, to to to know that, like, there are these clinics that you can go to. You do not have to go to an emergency room. But, like, it like, on its surface, like, it doesn't make sense why anyone would choose to go to an emergency room if they don't have to. But, you know, when you actually go down a level, like, that's a huge leap of faith. You know, the emergency room is always available to you. It has been always available to you for decades. There have been these new provider types that have come and gone over the over the years. And so it's a huge leap of faith if someone, particularly, you know, if they're supporting a family member who's experiencing behavioral health crisis, to try something new and untested. And so that culture change and getting that leap of faith to to be adopted by patients out in the community is a huge thing that you need to, again, build in that trust. Emergency rooms. Leading up to the the launch in twenty twenty three, we held many, many meetings with as many different emergency room clinicians and staff that we possibly could, and we literally put them in the same physical room as the CBHC providers and literally had them introduce each other and and, you know, put names to faces and all that. And so, like, when you have someone who's in your emergency room, refer them to, you know, this clinician who's right down the street. And to this day, it's so hard to change emergency room clinical practice and to get that message to permeate down to the frontline clinical staff that changes over, you know, every eight hours or twelve hours. And so that culture chain is still a work in progress. And then I think that, you know, we talked about this is a fundamentally different way of practicing. And so the actual providers themselves, there is a strong pull to just do things the way we used to do them as far as kind of a group practice model, but that's not what the community needs. That's not what we kind of set up. And so really trying to fight back against that gravitational pull and, you know, provide the appropriate scaffolding to ensure fidelity to the model, is also something that, you know, I've learned the hard way that needs to be prioritized well in advance. Lee, I wanna thank you for for talking with No. Us today. We're not done yet. I just wanna I just wanna say thank you partly because for the audiences, we we usually meet and we prep for these kinds of things, and we give I gave Lee we gave him an idea of what we're gonna and I've not asked many of the questions we actually have noticed. And you and you have just gone in. But I I think they were I think that's just how the conversation went, and it's been you've been just wonderful. Happy. Happy too. What so my final question, also, we didn't we didn't prep for, but it's in line with what you're talking about, the this this tremendous pull to the status quo Yeah. And this, vital need for culture change Yeah. In order to actually improve the way care is delivered for people in a way that will lead to better outcomes. Yeah. And and you end it with talking about, you know, being more fighting the fighting the pull to the status quo and providing the scaffolding. Is there a a a tangible example of maybe a government role in the fight against the status quo and the the contribution of the scaffolding? Just curious if anything comes to mind of, you know, I want the audience to be like, okay. This is my this could be my role as a government person and and really pushing in the direction of of culture change. Yeah. So, I mean, I think that's, you know, I think that what we've learned, in in Massachusetts is that the it's not even right to say it's the best way because it's it's essential. The essential way to kind of maintain forward movement and and prevent kind of the the reflex of snapback is to be very, very clear with what, what reality you are trying to to generate and what, what future you are trying to move towards and, be as objective as possible with what that looks like. And so I think for for us, you know, we are very clear with the, the access that we are expecting from our CVHC providers in this new treatment model. And, when you asked about, like, a concrete tangible thing, the first thing that came to my mind is something that many of our providers, our CBHC providers actually hate, in that we tried something very novel in that we actually are doing secret shopping and actually calling we you know, we're working with our our beaver health vendor partner, and, we have secret shopping process in which these CBHCs are getting called to assess access twenty four seven, three sixty five, no matter who it is, no matter what the insurance is, no matter what language they speak. And, our providers hate it because of what we're actually finding is that, like, we are we don't have a hundred percent access all of the time. And, but this is, like, one of the unequivocal like, you know, the the unequivocal north stars that we have set for ourselves in this initiative is, like, there needs to be twenty four seven through sixty five access no matter who it is. And, like so if we have someone who calls to try to get access and they're told that they that you're closed or that, you know, you you don't take this type of person or this type of patient or whatever, like, it's if there's a missed care opportunity in a treatment model that is supposed to have full access for care opportunities, then that's unequivocally, you know, not not in line with fidelity. And so, I think that for us, you know, we've tried to be as clear as possible what we are expecting, how we can measure that in in the most realistic way possible, and then holding, you know, ourselves and our providers accountable to it. And I think that, you know, in a model that is there's a there's a lot of autonomy, a lot of flexibility on the clinical side. So I think being very clear at least on parts of the process or the outcome that you, you know, you you won't budge on is gonna be really important. As a former, state employee myself, clear expectations and accountability are they go a long way. I love it. I love it. Thank you. Alright. We are nearing the end of the hour. We have one question in the q and a right now, Lee, that we'll get at, and I would welcome folks to put in some more. And I think we need maybe three minutes at the end to kinda close things out. So we've got some time, and and so we'll take the questions we get, if that's alright. Yep. So Rachel asked a little while ago, and I I just delayed on it because we were talking about culture and stuff, and it just it didn't, just didn't wanna lose that thread. But Rachel asks, we have services that cannot be billed on the same day as other services. If CCVHC provider provide us providers provide a service that was already completed by by another provider, how is that managed? Or because CCBHCs are bundled, there's no concern because the shadow billing has enough other services to justify the daily rate. So trying to get into Yeah. The nuts and bolts and and if you've encountered those and kind of what you might be able to share. Yeah. So, I mean, I think that the the the answer to this question is is basically that you can only have one daily bundle billed each day. And so I think that this is, part of the culture change as far as, you know, getting away from the mindset of having to bill and then get paid for every single unit of treatment. There are going to be times, and there's going to be days, and there's honestly many of the, many days are expected in which there will be multiple different interventions that day to a individual who walks through the door. They might have therapy. They might meet someone about their medications. They might talk to, you know, a a social worker or a care manager about, you know, some, health related social needs or something like that, and they get paid the one daily bundle. There's gonna be other times when someone comes in and they have maybe one service that day, but they still get the daily bundle. And so the idea then is that it all comes out in the wash and that the daily bundle is priced such that the average visit is what you get paid. And some days, you will provide, quote, unquote, you know, more than that or, quote, unquote, less. But because it's it's a daily bundle and you only can get one daily bundle, per day, then it all kind of, comes out at the end of of the year. And so, hope that answers the the specific question, that was asked. But, again, this is, again, trying to get away from really the the focus on each specific unit and more on what does this population need, what does this person in front of me need today. I'm muted. It did answer the question, I think. It makes me curious about the daily bundle and or, and just sort of what's the what's the learning process that you've seen from a state perspective on on, calculating that daily bundle? Because I can imagine you were like, ah, maybe it'll be like this. And then the the clinics are like, that didn't that didn't work. Try again. Yeah. Just Yeah. So I think, work in progress. You know? Always a work in progress. I mean, I think that, you know, we certainly spent a lot a lot of time trying to get the math right, you know, when the model went live. And I think now that our model is has been live for, you know, several years, I think we now can, have the benefit of actually looking to see how accurate it is it has panned out. And so, you know, we are, you know, looking at, you know, provider reported audited financial statements and trying to figure out, you know, who's, you know, doing well with this with this rate, who's doing not so well, and what are the the reasons for that to basically try to continue to hone this to make sure that it's the appropriate rate, you know, for the providers of of this care. And I think that, it's it's, you know, it's I think it's part and parcel of moving towards these types of payment models is that it's way more work than just setting a rate and forgetting about it. It's it's a live process. It's a dynamic process that is going to change over time and particularly as our providers in the care model changes as well. But in the end, that extra work is gonna be more than worth it for for the type of care that's being provided. Lee, I wanna thank you for all the work that you're doing Massachusetts and, hopefully, sharing with other states and learning from other states. It's it's, no doubt helping a lot of people in your state and and also for your your willingness to to join us for a brief, time today in between visits to the beach, which I hope you get back to. Yes. So thank you very much. I very much appreciate that. And we will follow-up on the did you call it bocce? Was it bocce? Yeah. We'll follow-up on bocce. Yes. And just just for all the folks listening, I'm actually on a week of vacation. So the trips to the beach, I work very hard in my role at MassHealth. And so if any of my MassHealth bosses are listening I'm very sorry about that. No. Yeah. I I don't go to the beaches Nope. During my workday. But this just happened to fall on this week. So yeah. Yes. No. That is that's good good clarification. Yes. He's not going to the beach on work hours. He's actually working on his beach hours. Yeah. Yeah. Yeah. So, thank you again. And, I think at this time, we are turning it over to Amy to close us out. Thanks again, Lee. Very much appreciated. Thank you again, Tom and Doctor. Lee, an engaging conversation. And Doctor. Lee, thank you for your leadership in Massachusetts. We do have a few closing reminders for our audience. So in a moment, you'll see a slide pop up on the screen. Great. Next week, we will be hosting a state webinar. It'll be hosted on July thirteenth at one thirty pm. It is a statewide webinar to discuss how accreditation supports burden reduction for our state partners. You can register with the link that I just submitted in the chat. We will provide an overview of how states utilize non duplication, announce the release of NCQA's Medicaid managed care toolkit, and discuss how NCQA can support states in meeting federal requirements, including the Medicaid and CHIP quality rating system requirements. Next slide. Lastly, while it was great to see so many of you virtually today, we'd love to see you in person. On this screen here, you'll see some spots our team will be at this summer. If you'll also be in attendance at any of these conferences, feel free to find us at our booth or email us at public policy at n c q a dot org to set up some time to chat. And lastly, thanks again for our audience joining and listening in and submitting all of the questions. Please be on the lookout for recording of this event as well as a blog in the coming days. We appreciate the time you took today to listen. And if you can spare just a few more moments, please complete the post event survey that will pop up in your browser as we end the call. Your is valuable so we can continue to feature wonderful speakers such as Doctor. Lee on our fireside chat series. Thank you again, and have a great rest of your day. Thank you.