FACT SHEET: Primary Care Access and Affordability

Fact Sheet & Highlights

An Act relative to primary care for you aims to make it easier for Massachusetts residents to access primary care services and help health care providers focus on the quality of services they provide.

Study after study shows that not only does access to primary care services improve health outcomes, but it significantly lowers overall health care spending.

To do that, the bill requires hospitals, other health care entities, and commercial insurers to spend more on primary care; invests in the next generation of Massachusetts doctors; and lifts up community health centers (CHCs).

The legislation supports CHCs, which serve as the primary community-based health service providers for neighborhoods around the state, by helping to level the playing field and ensure CHCs are paid an equitable rate.

In recent years, primary care spending comprised only 6.7 per cent of total commercial health care spending in Massachusetts, while investment in specialty care has skyrocketed. This bill seeks to, over time, bring that share to 15 per cent, in line with recommendations for a healthy primary care ecosystem. The bill requires health care entities to direct a minimum percentage of their overall spending toward primary care and gives the Health Policy Commission (HPC) enforcement mechanisms to ensure they are meeting this target.

The bill supports budding health care professionals by re-establishing a program to unlock matching federal dollars to invest in the primary care doctors of tomorrow. It also reduces burnout for established providers, like primary care doctors and nurse practitioners, by overhauling the payment system and cutting down on administrative burden.

This comprehensive package is informed by the recommendations of the Primary Care Task Force, which the Legislature established in the last legislative session.

Incentivizing Greater Investment in Primary Care

Requires Investment in Primary Care. Sets a primary care spending target for hospitals, health centers, and other health care entities to ensure they prioritize the importance of primary care without increasing overall health care costs. Requires that a certain percentage of all health care spending must be in the primary care space, thus counterbalancing the heavy investments in specialty care.

Incrementally Steps Up the Target. Opens the primary care spending target at 9 per cent, steps it up to 15 per cent after three years, then hands HPC the responsibility of setting the target to account for the ever-changing health care cost landscape.

Gives HPC Enforcement Powers. Empowers the HPC to enforce the new target, including escalating fines starting at $500,000 if an entity fails to improve after being flagged by HPC for insufficient primary care spending. Entities in violation of the spending target would first have a chance to boost their primary care numbers through a performance improvement plan (PIP) implemented by HPC. Penalties could also include HPC prohibiting these entities from accepting new patients.

Keeps Overall Spending Under Control. Creates a new office of Primary Care Policy and Payment within the HPC, as well as a Primary Care Technical Advisory Council comprised of experts from across the primary care field. Calls upon the office, in consultation with the council, and the Division of Insurance (DOI) to make recommendations to ensure that increases to primary care expenditures do not add to overall health care spending. Additionally, tasks HPC, in collaboration with the Center for Health Information and Analysis (CHIA) and the DOI, to monitor the primary care spending target and ensure increases to primary care spending do not add to overall health care spending.

Lifting Up Community Health Centers

Supports Neighborhood Health Care. Buoys CHCs—the main primary care providers for many neighborhoods around Massachusetts—with higher and fairer reimbursement rates that help them provide health care services to all members of the community.

Creates Sensible Parity. Requires commercial insurance companies to reimburse CHCs at least the same rates that MassHealth does for the same services. 

Growing the Primary Care Workforce

Fosters the Next Generation of Providers. Addresses workforce challenges by incentivizing medical residents to work in primary care or behavioral health fields and brings more primary care providers to Massachusetts through post-grad residency and fellowship placements.

Utilizes Matching Federal Funds. Re-establishes a Medicaid graduate medical education (GME) program used in most other states that unlocks one-to-one matching federal funds to help cover the costs of fellowships and residency programs. The Executive Office of Health and Human Services (EOHHS) would work with the League of Community Health Centers to develop the program, which could support dozens of professionals each year when fully scaled up.

Cutting Down on Administrative Burdens

Lessens the Administrative Burden on PCPs. Cuts down on the billing, payment, and prior authorization paperwork which can eat up significant chunks of time for overworked primary care providers such as doctors and nurse practitioners. Ensures that a more reliable payment stream flows to primary care practices, without requiring nickel-and-dime billing every time a patient walks in the door, by shifting towards a new uniform model.

Creates an Easier Payment Flow. Requires insurance companies to administer and large health systems to participate in an ‘advanced primary care payment model’ through which providers would be paid a monthly lump sum by commercial insurers and the Group Insurance Commission based on the needs of a practice’s patients. MassHealth already utilizes a similar model.

Ensures Collaboration with Industry Experts. Tasks the new Office of Primary Care Policy and Payment with creating the new payment model in consultation with the DOI and the new Primary Care Technical Advisory Council.

Increasing Transparency in Health Care Spending

Prioritizes Useful Data. Tracks Massachusetts’ primary care capacity and spending levels by collecting information from large health care entities and private health care insurers.

Collects Provider Capacity Info. Requires large health care entities to report data to HPC including their provider capacity, their staffing levels for full-time-equivalent primary care providers, their current primary care patient panel, allocation of expenses to support primary care providers, and non-claims payments from insurers to providers. Makes this information available in a transparent and publicly accessible way. 

Collects Health Plan Data. Instructs private health care insurers offering small or large group health plans to report information on expenses for administering prior authorization to CHIA.

###