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Legislation would double investment in primary care medicine, a health cornerstone

A proposed legislation, sponsored by state Senator Cindy Friedman, would change how primary care doctors are paid. The hope is such a reform will change patient experiences, while incentivizing even more physicians to enter the field.Adam Berry/Getty Images

In the four and a half years Dr. Wayne Altman and others have been working to overhaul primary care medicine across Massachusetts, access has only worsened.

Patients complain they are unable to get appointments or face lengthy wait times to see a new physician. A recent report by the Massachusetts Health Quality Partners showed that a third of the primary care workforce is over 60, and more primary care doctors in the state recently left the field compared to national averages.

However, the legislation put forward by a team led by Altman, a family physician in Arlington and professor and chair of the Department of Family Medicine at Tufts Medical School, and sponsored by state Senator Cindy Friedman, would change how primary care doctors are paid and double what insurers pay toward it. Altman hopes such reform will fundamentally change the patient experience, while incentivizing even more physicians to enter the field.

“I think we can achieve something historical that can be a national model for primary care in the US,” Altman said.

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The legislation is already facing pushback from some health care groups, in particular over a proposal for insurers, hospitals, and pharmaceutical companies to put money into paying for the plan.

“The ideas are the right ideas. But some of the mechanisms are flawed,” said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans.

Primary care is considered by many to be a cornerstone of medicine, keeping patients healthier and avoiding more costly intervention down the line.

The “Primary Care for You” legislation, which will be the focus of a Joint Committee on Health Care Financing hearing Tuesday, is only the latest time the state has sought to reform primary care. Former Governor Charlie Baker tried twice — in 2019 and again in 2022 — with proposals that would have required providers and payers to increase spending on behavioral and primary care by 30 percent over three years.

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The recently proposed legislation by Altman seeks to double the percentage the state spends on primary care in three years, from 6-8 percent to 12-15 percent.

The bill would also rethink how primary care doctors are paid. Currently, the vast majority of doctors for the vast majority of their patients are paid for each visit, test, or procedure they perform — a payment method known as “fee-for-service.”

To incentivize quality, rather than quantity, of health care, some doctors have partnered with insurers in different ways of payment. According to the Center for Health Information and Analysis, the most common alternative payment method in the state is “global budgets,” which establish spending targets for a comprehensive set of health care services to be delivered to a specified population.

But Altman argues that even in such alternative payment contracts, doctors are often compensated based on their productivity and how many patients they see in the office.

“What we’ve done is rearranged the deck chairs of our Titanic health care system,” Altman said. “We can’t do that anymore. This [bill] is a non-incremental approach that is fundamentally shifting the way we administer and pay for primary care.”

Instead of being paid after the fact, Altman’s proposal looks to shift payments more in line with recent Medicaid reforms. Under his plan, doctors would receive payments upfront — amounts based partially on historical reimbursement revenue per patient over the past two years and also on the average statewide per-patient monthly revenue amount.

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Patients at a practice that opts into the new model won’t have any copays or deductibles for primary care services, and providers would just deliver the care as they see fit without worrying about billing for individual services.

Currently, providers can receive higher reimbursements by meeting 40 different quality metrics. Altman has proposed 10, of which practices can hold themselves accountable to five.

Practices can also select from a menu of 17 add-on services for even higher reimbursements, such as integrated behavioral health, medical interpreter services, or telehealth, the cost for which would be more than borne by the increased upfront reimbursements, Altman argues.

These payments for commercially-insured patients, which must go directly to the primary care office rather than the insurer or a third party, will come from a “Massachusetts Primary Care Trust,” paid for by a tax on large health system reserves, insurer surpluses, and pharmaceutical companies based on their Massachusetts market share. The proposal also suggests capping the rate of growth on hospital prices to increase investment in primary care without going over the state’s health care benchmark, a state goal to limit annual growth of health care spending.

Rather than a set-in-stone directive for reform, Senator Friedman, an Arlington Democrat, views the legislation as a conversation starter.

“The bottom line is we have to get more money into primary care, we have to get more doctors and providers in general to deliver primary care, and we have to do it with a great sense of urgency,” she said.

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The legislation has a slew of endorsements, from the Massachusetts Academy of Family Physicians to the Massachusetts Chapter of the American Academy of Pediatrics.

“Strengthening the primary care system is a cost-effective way to help drive more equitable health outcomes and has been associated with lower emergency department use and hospitalizations,” said Amy Rosenthal, executive director of consumer advocacy organization Health Care For All, in a statement noting the organization’s support of the bill.

But insurers balked at the idea that providers would be paid outside of their contracts, which Pellegrini said could lead to the system paying twice for primary care.

“The proponents came to us in recent weeks to provide them with language that would be acceptable and we plan to do that,” she said. “We are supportive of efforts to increase spending in primary care and behavioral health, but the mechanism in this bill we cannot support.”

Friedman said all stakeholders in the health care market have to contribute to a solution. Further, she said even as groups put money toward this initiative, they would still have to operate within the state’s cost growth benchmark.

Without action, Friedman said the state could expect to see higher costs as people sought health care in more expensive places, and an erosion of health equity as the most vulnerable went without care.

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“I think we cannot solve our quality, equity, and cost issues if we don’t address our primary care piece,” she said. “I really hope all parties are taking this seriously. It’s a problem, and we can’t continue to do business as usual.”


Jessica Bartlett can be reached at jessica.bartlett@globe.com. Follow her @ByJessBartlett.