The Massachusetts Medical Society is a professional association of over 25,000 physicians, residents, and medical students across all clinical disciplines, organizations, and practice settings. The Medical Society is committed to advocating on behalf of patients, to give them a better health care system, and on behalf of physicians, to help them provide the best care possible. In striving for health equity and optimal medical care, the Medical Society endorses legislation that seeks to improve affordability and accessibility of health care in the Commonwealth. For that reason, the Medical Society wishes to be recorded in support of S.750, An Act Relative to Primary Care for You, which offers critical reforms to increase investment in the primary care system with the goal of improving patient access to care and overall population health.
A high-functioning primary care system is critical to the overall health care system, and is key to better health outcomes, lower costs, and more equitable access to care. Robust access to primary care services improves overall population health and may reduce avoidable emergency department visits. The Medical Society seeks to foster a system of primary care that delivers equitable access to all, that incentivizes practice transformation toward a comprehensive model of care that significantly increases the funding for primary care, and that allocates resources in an equitable fashion. Increased investments in primary care can promote higher quality and lower-cost care across the health care system. The role of the primary care physician in coordinating care is key, especially for an increasingly aging population with high rates of chronic disease and for the pediatric population, where primary care physicians can address adverse childhood experiences and promote optimal health and development at crucial points in a child’s life. This vision of primary care is not and cannot be realized in our current system, which incentivizes volume over quality.
The Medical Society is concerned about the sustainability of primary care practices in Massachusetts, especially as the COVID-19 pandemic has caused unprecedented challenges and disruptions across all health care settings. We hear too often from our members in primary care that the system right now is broken and does not adequately value or invest in primary care. The Massachusetts Center for Health Information and Analysis (CHIA) in collaboration with Massachusetts Health Quality Partners (MHQP), has published Massachusetts’ first-ever dashboard of metrics to monitor the health status of the primary care system in the Commonwealth. Spending on primary care as a percentage of total medical spending in 2021 was 6.9% of total medical spending for commercial patients, 6.0% of spending for MassHealth MCO/ACO-A patients, and 4.2% of spending for Medicare Advantage enrollees. Primary care spending represents less than 6.4% of overall medical spending and while this represents a decline from 2020 data, it is not directly comparable due to differences across data collection periods in the underlying list of health care claim procedure codes used to identify and define primary care.
The dashboard also highlights well documented issues regarding shortages in primary care providers and racial & ethnic disparities in access to and utilization of primary care providers. For example, in 2021, only 64% of Hispanic residents reported that they had a preventive care visit in the last year, versus 81% of White residents. Those disparities are underscored in a separate 2022 CHIA research brief showing that Black and Hispanic residents report higher likelihood of reliance on hospital emergency departments for health care than white residents for non-emergency conditions, which underscores the degree to which racial disparities underly emergency department use, which stem from factors like lack of access to community-based primary care – and this comes at a time when emergency departments statewide are currently buckling from system-wide capacity constraints.
Primary care practices – including pediatric practices – are deeply strained financially, as they are amongst the lowest reimbursed in both the commercial and public markets. On top of that, practices are contending with ever increasing practices costs, exacerbated by labor shortages across all medical professionals. In short – our system is in severe distress and in need of transformative changes to invest in and prioritize access to primary care services. That change has been proposed through S.750, An Act Relative to Primary Care for You, which transforms the predominant payment model for primary care from a fee-for-service model to monthly prospective payments and proposes to double investment in primary care through incentivized payments for meeting designated health transformers. This legislation will advance health equity by supporting primary care practices and incentivizing expanded services and programs to integrate behavioral health and substance use disorder services and to improve health, patient experience, and clinician experience, which ultimately increases patient access to care and affordability.
While the Medical Society supports the concept and intent behind this proposal to invest in primary care as necessary and transformational, we acknowledge that the lack of specifics and guidance relative to most appropriately and equitably achieving such a significant increase in spending on these services over such a short period of time, especially in light of the incredible strain on the health care system at this time. This proposal is very similar to the new Massachusetts ACO primary care sub-capitation program, which is still in its early stages and has not yet been fully evaluated. However, at its core, the per-member, per-month (PMPM) rate offered to participating primary care physicians is critical and must be adequate to financially support practices – while details are lacking, it is important that rate setting factors account for inflationary updates, labor costs, practice expenses, etc. beyond just historical rates.
Another key question that must be addressed is how increased investments envisioned in this legislation will be paid for – while we agree that over time, savings from increased investment in primary care will pay for itself, there must be an explicit plan for initial costs. This may require substantial financial infusions at the outset, which likely must come from state coffers or some combination of public and private dollars, in order to support practices – particularly smaller, independent practices – without the capital needs to invest in the staffing, technology, and equipment to access the benefits of the transformers. To deliver high quality care, primary care physicians need a team - not just of well-trained medical assistants and nurses, but with patient navigators, case managers, and social workers – appropriate staff to address issues of care management, disease management, and health-related social needs. This level of care requires robust investment and support.
Lastly, the Medical Society has some concerns about the feasibility and practicality of some of the proposed provisions. Specifically, while it makes sense to implement an aggregate primary care expenditure target that increases year-over-year, we question the feasibility of instituting individual expenditure targets for every single primary care practice in the Commonwealth – not only does CHIA likely not have the capacity to do so, but small practices and solo practitioners may be held to unrealistic expenditure increases/standards without any financial support to make the necessary investments to achieve the target. With the 2017 1115 Demonstration Waiver establishing the ACO program, there was a bucket of DSRIP dollars that were given out to entities to help invest in the wrap around services and additional patient supports – this is critical.
To help answer those questions, the Medical Society looks forward to working constructively and collaboratively with key stakeholders within and outside the legislature to build upon this proposal to most appropriately and effectively advance the underlying goals of this bill. To be sure, certain aspects of this proposal require further refining, but we must act this session to ensure the viability and sustainability of primary care in the Commonwealth. Thank you for consideration of our comments, we look forward to working with you.
View a PDF version of this testimony here.
