Hundreds of independent primary care organizations in Massachusetts will see sizable increases in Medicaid reimbursement next year, as state officials move to stabilize an industry facing severe financial challenges.
Practices with a high percentage of patients on Medicaid, a government insurance program largely for low-income people, have been struggling with reimbursement rates that are too low to cover rising expenses. Providers have been closing as a result, increasing the burdens on those that remain.
The increase announced this month by MassHealth may relieve some of that pressure. The hike comes after The Boston Globe highlighted the issues confronting independent pediatric practices. Dr. Aaron Bornstein, co-owner of Middleboro Pediatrics in Lakeville, said he has since sensed a shift in the regulatory landscape.
“The acknowledgement, recognition and prioritization of all of this as it’s going forward is what feels new to me,” Bornstein said. “That discussion wasn’t happening, at least not publicly in this way. It’s very encouraging.”
The reimbursement rate increases range from 25 percent for adult patients to 35 percent increase for pediatric members. To qualify, a provider must meet several criteria, including being an independent practice that participates in an “Accountable Care Organization.” Providers with that designation have a special set of reimbursement guidelines under MassHealth designed to incentivize quality over quantity.
There are 360 primary care practice organizations that participate in the state’s ACO program, which sees 1.2 million members at their combined 1,000 practice sites. The increases affect about 85 percent of those organizations.
A spokesperson for MassHealth said the increases were a recognition that group practices are an important part of the primary care delivery system, and that they are facing unique structural and financial challenges. While health centers and hospitals have received substantial MassHealth rate increases in recent years, group practices have not.
Bornstein said even with the increase, the Medicaid reimbursements are still insufficient. However, they are a start.
“This brings a fair amount of optimism,” he said. “You feel like you’re losing money when you see a MassHealth patient for anything other than a physical, because you kind of are. To get funding closer to what is commensurate for other patients feels more sustainable. That should make a difference covering some of the expenses we’ve had.”
As helpful as the increases will be to hundreds of physicians in the state, they won’t be universal. Practices that accept MassHealth patients but who are not in the ACO program will continue to be paid at current MassHealth rates, the state said, though MassHealth couldn’t detail how many practices are operating.
Atkinson Family Practice in Amherst and Northampton are among the practices that will not see an increase. Though an independent family practice, it does not participate in the ACO.
Owner Dr. Katherine Atkinson said low MassHealth payments were a hardship before the pandemic. But with payroll and other costs skyrocketing in the years since, the reimbursements are now “untenable.”
“Our situation is very dire,” she said. “We’re fighting to keep open.”
As it stands, Atkinson said she loses money on every MassHealth patient that she sees. She said the state needs to do more to help private practices such as hers, particularly those that offer comprehensive medical and behavioral health care in one space.
“This is my dream, to have a collaborative practice with medical and behavioral subspecialties working together,” she said. “I’m watching my dream crumble.”
Even as MassHealth looks to improve some rates, physician groups are advocating for more comprehensive reforms.
Dr. Barbara Spivak, president of the Massachusetts Medical Society, said the crisis in primary care has been exacerbated by workforce challenges. Doctors have increasingly left the industry. Low salaries in primary care have further dissuaded newcomers from joining their ranks.
Practices are also struggling to fill other roles. All the hiring challenges have made it hard for practices to staff up sufficiently to see more patients.
Beyond the reimbursement concerns, primary care doctors say they are struggling to manage administrative burdens — from the tasks associated with insurance reimbursement to simply managing all the urgent messages in their inboxes.
In a letter to the state’s Executive Office of Health and Human Services, Spivak asked the administration for further enhancements to Medicaid reimbursement, including a $7 million infusion of capital for needs such as hiring more social workers.
Even as she celebrated the reimbursements that her organization helped champion, she said they were a start to addressing the problem.
“There’s a lot of other work to be done to get (primary care physicians) where we need it to be,” Spivak said. “But MassHealth has taken one aspect of it that they can impact and tried to improve it.”