First, the state should increase the proportion of total health care spending that goes toward primary care.
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CHIA reported that in 2024, just 6.6 percent of spending by commercial health insurance and 8.4 percent by MassHealth went to primary care. Certain specialty procedures are justifiably more expensive than a primary care office visit. But the problem with paying too little for primary care is that if physicians don’t earn enough, they will leave or never enter the field, leading to doctor shortages. When a patient can’t get preventative care, they seek care in more expensive settings, like the emergency department.
One study comparing primary care across 10 high-income countries found the United States had among the worst access to primary care. One likely reason: The United States spent 4.7 percent of health care dollars on primary care in 2021, compared to 14 percent on average in other countries.
States including California, Oregon, and Rhode Island have set goals of increasing the proportion of health care money spent on primary care. The Massachusetts Health Policy Commission’s primary care task force recommended Massachusetts set a primary care spending target of either 15 percent or doubling current spending by 2031, whichever is more.
The Senate bill would initially set a target of 9 percent, increasing to 15 percent over three years. The Health Policy Commission would enforce the target by imposing fines and requiring performance improvement plans from providers and insurers that don’t meet the target.
The challenge, of course, is that it will be up to each provider to figure out where to take the money from to increase investment in primary care, at a time when hospitals are losing money due to changes in federal policy. It will be important to have audits and strong enforcement to ensure the mandate doesn’t drive up overall health care costs but rather shifts where money is spent.
The second principle is moving away from the traditional fee-for-service model of insurance, where a doctor is paid for each service, toward a model where doctors are paid a per-patient amount to provide a bundle of services and keep that patient healthy.
There are different types of alternative payment methods, but the rationale for all of them is to eliminate the administrative burden of seeking reimbursement for every service and to incentivize more efficient care. For example, under fee-for-service, a doctor is more likely to tell a patient to visit the office for an issue that could be addressed with a phone call, because the doctor isn’t paid for the phone call.
The Health Policy Commission’s primary care task force has made recommendations for what a payment model could look like with a single payment per member per month, adjusted based on the patient’s risk profile. More money would be given for enhanced services like after-hours care and for good outcomes.
Developing an insurance model that works across different types of insurance plans and health care providers, and that ensures all types of patients are well-cared for, won’t be easy and will take collaboration between state insurance regulators and the industry. But there are models to explore, and MassHealth has already started moving in this direction.
Finally, as this board has previously argued, Massachusetts should use state Medicaid money to fund medical residencies in primary care. Massachusetts is one of just seven states that don’t use state funds for this purpose. Finding money to put toward residencies won’t be easy, but it would bring additional federal dollars into Massachusetts while letting the state tailor the program to train doctors in fields and locations where they are most needed — like in primary care at community health centers.
Too many doctors are leaving primary care because they are burnt out or can’t make enough money while providing quality care. Too many patients can’t see a doctor when they need one. Changing the system will require bold steps.
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