At the heart of his biggest health care initiative as governor, Charlie Baker is proposing a fundamental shift in how Massachusetts delivers care.
Baker has called for new mandates to increase the amount of money health care providers and insurers spend in two critical areas: primary care and mental health care. It’s a long-term bid to change priorities and refocus the health system on services that can help prevent and manage disease and reduce costly procedures and hospital stays.
The plan — part of a broad 179-page health care bill — has critics. It could be tricky to implement and enforce in a way that doesn’t raise overall costs. It is also far from gaining the support of the Legislature and becoming law.
But the principles behind the governor’s proposal are rooted in research, including evidence from neighboring Rhode Island, where standards for primary care spending have been in place for a decade.
While the numbers vary from state to state, as a share of total health spending, the United States on average spends less on primary care than its peer countries. Instead, the vast majority of health care dollars here go to hospital services, specialty care, and prescription drugs. This is at least partly because the prevailing system of payment for health care in the United States values expensive procedures and treatments over primary care office visits.
“The system is out of balance, and there should be a reallocation,” said Christopher F. Koller, president of Milbank Memorial Fund, a foundation that conducts health policy research.
Massachusetts officials estimate that about 11 percent to 15 percent of health care dollars in the state are spent on primary care and mental health care. The governor’s plan would require insurers and providers to increase their current spending in these areas by 30 percent over three years. But it’s vague on the details of how they could arrive at that spending goal. Those that don’t comply may be required to draft a plan for achieving the target, and if they fail to come up with a plan, they could face fines.
To keep costs in check, the administration also would require insurers and providers to continue to adhere to the state’s overall health care spending benchmark, which requires they keep their growth in spending to 3.1 percent per year.
This essentially requires a redistribution of dollars, from high-tech medicine to low-tech encounters between patients and caregivers.
Primary care practices would welcome additional funding that could help them more efficiently take care of patients, said Dr. Russell S. Phillips, director of the Center for Primary Care at Harvard Medical School.
“Primary care is really in crisis right now,” he said. “There just aren’t sufficient resources.”
With more money, clinics could hire additional staff, such as social workers to treat patients with mental illness, nurses to manage care for patients with chronic diseases, health coaches to help patients lose weight and quit smoking, and community health workers to help patients access healthy food.
Additional funding would also help doctors enlist scribes to take medical notes, so they can spend more time face-to-face with patients, Phillips said.
In addition to benefiting patients, such changes could draw more physicians to the field of primary care, he said, where there is a well-documented shortage of providers.
Danna Mauch, president of the Massachusetts Association for Mental Health, said the governor’s proposal sets a reasonable — if modest — target for spending. The new funding should be used not just to increase reimbursements for mental health providers, she said, but to expand programs to patients in need and to integrate these services with primary care.
“This is feasible and achievable and would be done by using evidence-based practices,” Mauch said.
Baker and his health secretary, Marylou Sudders, spent two hours making the case for their plan at a legislative hearing Tuesday. Baker argued that the current trajectory of the health care system is unsustainable and that insurers and providers must change their priorities.
“We will never solve the health insurance cost problem ... until we change the way we actually deliver services,” he said at the all-day hearing.
A 2019 report from a nonprofit group called the Patient-Centered Primary Care Collaborative found links between increased primary care spending and fewer emergency department visits and hospitalizations.
There are different ways to measure primary care. The broad definition includes care provided by family doctors, internists, OB-GYNs, pediatricians, and nurse practitioners — as well as behavioral health professionals.
In 2010, Rhode Island officials introduced a set of "affordability standards” that imposed price controls on providers and required insurers to increase their spending on primary care by 1 percentage point per year for five years. Health spending slowed in Rhode Island after those rules were implemented, according to a 2019 study in the journal Health Affairs.
“It was disruptive,” said Koller, who was Rhode Island’s health insurance commissioner at the time. “It articulated a priority for the health system.”
The state’s mandate for increased primary care spending allowed providers such as Coastal Medical to transform how they deliver care, said Dr. G. Alan Kurose, chief executive of the organization, which has 20 medical offices across Rhode Island.
The money helped Coastal Medical hire pharmacists, nurses, medical assistants, patient navigators, and data analysts, among other new staff. Coastal opened an urgent care clinic and built programs to help patients with diabetes and chronic lung disease manage their conditions.
“It had a huge impact,” Kurose said. “By having quality incentive payments, it allowed us to be very creative, to implement a full range of services we didn’t have before.”
Policy makers in Oregon followed with their own plans to refocus attention on primary care. A 2017 state law set a target of increasing primary care spending to at least 12 percent of total spending by 2023.
“It was a combination of ‘We need to focus more on primary care, but we also need to do it in a way that better coordinates care for patients,’ ” Jeremy Vandehey, director of health policy and analytics at the Oregon Health Authority, said of the state’s efforts. Oregon is also in the process of establishing a target for total health spending, similar to the benchmark in Massachusetts.
Massachusetts lawmakers are planning to work on health care legislation this year, but it’s unclear if they will follow Baker’s lead on primary and behavioral health care.
Several legislators voiced support for the governor’s ideas Tuesday, but some also hinted at other priorities. Representative Daniel Cullinane, vice chairman of the Joint Committee on Health Care Financing, repeatedly raised the issue of struggling community hospitals and health centers and questioned whether Baker’s bill would do enough to help them.
If some version of the governor’s plan does become law, the details will be important.
Some specialists worry that the focus on primary and mental health care could leave less money for other important services. Dr. Rodrick Williams, president of the Massachusetts Radiological Society, said the governor’s plan could end up encouraging insurance companies to cut back on coverage for certain mammograms, for example.
“If you’re going to do the increase in primary care spending and behavioral health spending — which is wholly appropriate — we’d be concerned that people would arbitrarily cut spending where it shouldn’t be cut,” Williams told the Globe.
Dr. Steven Strongwater, chief executive of Atrius Health, which includes Harvard Vanguard and other medical practices, said the requirements to shift spending should be on insurers — not on providers. And he said he believes the state’s highest-cost health care providers shouldn’t be eligible for additional funding.
“It’s the administration of the funds: We want to make sure it’s done carefully and thoughtfully to avoid making the cost of care in the Commonwealth worse,” he said.
A new infusion of funding would help Atrius extend clinic hours, expand the use of tele-health, and hold hourlong appointments for complex patients, among other changes, Atrius officials said.
Lora Pellegrini, president of the Massachusetts Association of Health Plans, said insurers support investments in services that "are the backbone of the health care system.”
But, she added, “It has to be done within the cost benchmark.”