NewPublicHealth Q&A: John Auerbach and Cheryl Bartlett on the Massachusetts Prevention and Wellness Trust

Dec 9, 2013, 2:25 PM


The Massachusetts Prevention and Wellness Trust is a four-year, $60 million project designed to support prevention and health-promotion activities in the state. The first project of its kind in the United States will fund six to 12 collaborative initiatives, and partners on the initiative will include municipalities, community-based organizations, health care providers, regional agencies and health plans. Information on the Trust is detailed in a new report prepared by the Institute on Urban Health Research and Practice at Northeastern University and funded by the Robert Wood Johnson Foundation.

The vision behind the creation of the project is to give all Massachusetts residents the opportunity to live in communities that promote health, as well as seamless access to all community and clinical services needed to prevent and control chronic diseases. It was created because while there is access to health insurance and health care in Massachusetts, health costs continue to rise. The goals of the project include:

  • Reducing the rate of the state’s most costly preventable health conditions
  • Reducing health disparities
  • Increasing healthy behaviors
  • Increasing the adoption of workplace wellness programs
  • Developing a strong evidence base of effective prevention programs

In order to implement these goals, the Massachusetts Department of Public Health identified four priority areas: tobacco use, childhood asthma, hypertension and elder falls prevention—all of which should be considered closely when working to reduce health disparities and co-occurring mental health conditions in these areas.

Massmodel Detailed look at a section of the new infographic

A new infographic created for the Prevention and Wellness Trust’s inauguration perfectly illustrates how community links work together to improve health under the principles of the Trust. For example, a diagnosis of hypertension would need a provider to prescribe medications, but the obesity and exercise needs that would also improve the condition for many patients requires input from other community entities, including:

  • Classes in exercise, medication and stress reduction by community agencies
  • Chronic disease self management classes and home visits for medication use instruction by a community agency
  • A neighborhood policy that provides support for transportation changes to encourage walking or biking and zoning for healthy food stores
  • A neighborhood policy that provides support for more accessible recreation options in parks and city centers for increased stress reduction
  • Workplace policies that provide support for workplace wellness programs that help provide and encourage exercise, healthy foods and stress reduction

NewPublicHealth recently spoke with John Auerbach, a Professor at Northeastern University and the primary author of a report on the Trust, and Cheryl Bartlett, public health commissioner of Massachusetts and the lead person charged with its implementation.

NewPublichealth: How did the Massachusetts Prevention and Wellness Trust come about?

John Auerbach: While a great deal of attention to Massachusetts has focused on our near universal healthcare reform initiative passed in 2006, there actually have been a series of other groundbreaking health bills in the state. The one that created the Trust passed in 2012 and was focused in particular on the issues of cost and quality. There was an opportunity to talk about the contributions that prevention could make in addressing the concerns around both of those areas.

Once the concerns about access to care had been largely addressed under health reform, that allowed a broad coalition of organizations and government officials to focus on other issues that were as important, such as quality, cost and disease prevention.

NPH: In addition to having moved ahead on access to care, what do you think made Massachusetts a strong state to move ahead on tackling prevention and wellness?

Auerbach: Massachusetts really does have some pride in tackling hard issues and thinking outside the box, trying new things if there appears to be evidence that they are likely to offer promising outcomes. I think we’re also unusual in the state in that we’re able to address those issues in a way that crosses the aisle so that people from different political parties sometimes sit at a table and think about solutions that are in the best interest of the public.

NPH: What were some of the critical decisions that brought the Trust about?

Cheryl Bartlett: We decided that primary prevention couldn’t really be the major focus of this funding or we would not get the return on investment we needed to convince the legislature of the need for continued funding. So we came to the conclusion that secondary prevention (or, finding and treating disease early to prevent further complications) was the way we would get the fastest return on investment. We also took a lot of time going out into the community and meeting with advocates we needed on board. Those efforts made stakeholders strong supporters.

Auerbach: Broad support for passage of the Trust was built on the experience of a coalition of organizations that originally worked on the health care reform initiative in 2006. They learned that major pieces of legislation require broad coalitions that include diverse organizations. Among those involved were insurers, health care providers, public health officials, faith-based community groups and legislators such as the Senate President. All of those groups had to come to the table and put aside some of their very specific differences for a larger good.

And then Commissioner Bartlett had the very challenging task of implementing the Trust in a way that would meet the diverse needs of different constituencies. I think she has skillfully overseen that process.

NPH: How is funding allocated and what will it go toward?

Bartlett: The Trust fund is $60 million, with $3 million for other cost-containment efforts. So that gives us $57 million over four years, of which 75 percent goes to prevention and wellness grants to diverse regional collaboratives. With guidance from the Prevention and Wellness Advisory Board, we established the guidelines for funding. Applicant teams had to minimally include a municipality, a community-based organization, an accountable care organization, a community health center and a group of providers. They needed to apply as a formal collaborative to guarantee the community/clinical linkage that was needed—the kind that is so often talked about in health care reform.

We needed the inclusion of community-based organizations that can provide care in settings that are much more conducive to promoting health than are hospitals and emergency rooms. The clinical providers have to link with these community-based organizations and show a return on investment in a four-year time period—with all participants as equal partners.

Our intent is to show the health care providers that in a global payment model there is room for community-based partners that can help them achieve better care coordination and cost reduction. Our goal is to be budget neutral, showing that by spending $60 million we can save $60 million.

We developed a financial calculation similar to that of the federally funded community transformation grants. With such an approach we estimated how much we needed to spend per person in order to generate the health care cost savings.

Each of the six to 12 grants to the regional collaboratives will get initial start-up funding and then as much as $1 million per year for the three remaining years.

NPH: What happens at the end of four years? What will you be looking for and do you hope more money will be allocated?

Bartlett: We will probably be using a lot of hospitals admission and emergency room use data to show outcomes. We hope to show a significant reduction in hospitalizations, which would allow for continued funding.

Our big hope is that we can demonstrate to the legislature that it funding public health is wise and supports the goals of health care reform. Through our approach we can help link health care providers with community-based care and achieve their goals of reducing costs and improving health outcomes.

Auerbach: Linking health care and community initiatives can assist in addressing the social determinants in people’s lives in a meaningful way. You can complement accessible, high-quality clinical care with attention to what’s happening in people’s neighborhoods, schools and workplaces.

I don’t think anything like that has ever been tried on a statewide basis. The significance of this will be demonstrating concretely to a wide range of different organizations and practitioners that there’s a new way to think about high quality care that goes beyond the likely demonstration of a return on investment.

NPH: Was there a model for the Trust fund?

Auerbach: I would say it was an innovative idea, however, there were examples of efforts that were helpful in coming up with the model. The Affordable Care Act’s Public Health and Prevention Trust, for example, allocated hundreds of millions of dollars to community transformation grants.

Bartlett: We did ROI analysis projections for how many preventable hospitalizations we needed to achieve the target cost savings of $60 million over four years. We provided information to the Advisory Board on the top 13 most-preventable health conditions and risk factors that have evidence-based strategies with measurable outcomes and cost savings. Each advisory board member prioritized the list and we came out with the four conditions we’re using for the Trust. Applicants for grants were required to choose at least two of the four conditions and design a collaborative approach for community-clinical linkages to support care coordination and health promotion at a local level.

>>Bonus Link: Read a White Paper on the Massachusetts Prevention and Wellness Trust prepared by the Northeastern University Institute on Urban Health Research and Practice.

This commentary originally appeared on the RWJF New Public Health blog.