Transformative Legislation Proposed in Massachusetts: Primary Care for You (PC4You)

Proposed legislation to increase investment in primary care and decrease health inequities

The Massachusetts House and Senate have referred a new bill on primary care to the Joint Committee on Health Care Financing. This bill, Senate No. 750, is sponsored by Senator Cindy F. Friedman and has three goals: 1) double primary care investment, 2) decrease health inequities, and 3) transform the predominant payment model for primary care from fee-for-service to a monthly prospective payment.

Spending on primary care accounted for 7.6% of total health care dollars spent in Massachusetts in 2020. The Primary Care for You (PC4You) Legislation proposes increasing primary care spending to about 12 to 15% of overall health care expenditures by 2029. This would be accomplished by requiring all commercial payers in the Commonwealth to offer a prospective, per patient per month payment to all primary care practices who chose to opt in.

While a new multistakeholder Primary Care Council would guide the implementation, the legislation spells out a general model for this new payment approach. The monthly payments would be adjusted by 1) the provider’s adoption of primary care transformers, 2) the quality of patient care delivered, and 3) the clinical and social risk of a provider’s patient panel.

The primary care transformers are a set of interventions that improve health, patient experience, and clinician experience, and decrease total medical expenditures. These transformers include a range of interventions that could be implemented within primary care practices, leverage community connections, and also enable primary care practices to better coordinate with other health care entities, such as: community health workers, health coaches, investing in social determinants of health, pharmacist collaboration, behavioral health integration, substance use treatment, telehealth, medical interpreter services, home care, patient advisory groups, medical scribes, care management, advance care planning and palliative care, and extended availability of primary care offices.

This payment model would reduce barriers to primary care by removing cost sharing for patients. This means patients would not be responsible for co-payments, co-insurance, or any deductibles when accessing primary care.

The bill would create a Primary Care Trust to distribute the monthly prospective payments for all commercial patients, significantly decreasing the administrative burden of primary care practices. It would be administered by the Health Policy Commission who would receive payments directly from commercial payers.

High-quality primary care is the foundation of health care

Underinvestment in primary care is an oft-cited reason for why the US healthcare system outspends and underperforms peer high-income countries. Spending on primary care in the US has been trending down. From 2002 to 2016 it decreased from 6.5% to 5.4% of total health care spending. It continued to decrease down to 4.7% in 2019. In comparison, Great Britain spends 12% of its health care budget on primary care services and the average for Organization for Economic Cooperation and Development (OECD) countries is 13.1%.

The National Academies of Sciences, Engineering, and Medicine released a 2021 report, Implementing High-Quality Primary Care, declaring high-quality primary care the foundation of a high-functioning health care system. Research suggests that greater investment in primary care results in lower health care costs, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. In 2019, the US spent 17% of GDP on healthcare – more than 8 percentage points above the average of OECD countries. In 2021, the CEO World Magazine Health Care Index ranked the US healthcare system 30th out of 89 countries.

States are investing in primary care

State policy action to increase investment in primary care is gaining traction. For example, California conducted a study in 2022 showing that investing in primary care could save $2.4 billion annually and avoid 89,000 emergency room visits. Several states are setting primary care spend targets through legislation:

• Rhode Island setting a target of 10.7% in 2010,
• Connecticut setting a target of 10% by 2025,
• Delaware targeting 11.5% by 2025, and
• Oregon requiring a minimum 12% primary care spend by 2023.

Many other states such as Colorado, Nebraska, and New Mexico have passed legislation to establish a formal entity to evaluate and advise on primary care spending.

Massachusetts is already considered a top-performing state in terms of primary care spend percentage by the Primary Care Collaborative. However, given the potential to improve patient care and decrease costs by investing in primary care, Senate Bill 750 could save lives, reduce emergency room visits, enhance access and equity, and reduce spending.

Leadership and endorsements

This legislation has been spearheaded by the MA Primary Care Alliance for Patients (MAPCAP). MAPCAP is a group of primary care leaders, patients, and other stakeholders in Massachusetts who advocate for healthy equity through improved funding for primary care. Notable endorsements for the bill have come from the Massachusetts Academy of Family Physicians, Health Care for All, the Massachusetts Association for Mental Health, the Massachusetts Medical Society, and UMass Memorial Health and their CEO Dr. Eric Dickson.

The Joint Committee on Health Care Financing will host a hearing on the bill in the coming months – likely this summer or fall. If you’re interested in voicing your opinion on this bill to your legislator, you can find your representative and their contact information here.