Massachusetts Health Policy Commission

This document, Statutory Deliverable #4 from the Massachusetts Primary Care Access, Delivery, and Payment Task Force, proposes payment models to increase reimbursement for primary care and address the primary care crisis in Massachusetts. It advocates for a shift from traditional fee-for-service to multi-payer aligned Alternative Payment Models (APMs). The plan outlines core goals including improving patient access and experience, strengthening primary care capacity, supporting team-based care, enhancing quality and health equity, reducing administrative burden, and improving workforce sustainability. Key recommendations involve establishing an Advanced Primary Care Payment Model with prospective, capitated payments, ensuring multi-payer implementation, and mandating robust monitoring and accountability for its effectiveness and uptake.

The meeting included introductions and welcoming remarks. Key discussion topics centered on the launch of the new Healthcare Affordability Working Group, which is expected to leverage the task force's recommendations. The agenda also involved sharing findings from a recent Milbank report highlighting the value of primary care in reducing chronic disease burdens, hospitalizations, and healthcare expenditures. The bulk of the session was dedicated to continuing the discussion on statutory deliverable number four, focusing on payment models, and an open discussion on deliverable number five concerning health plan design improvements for primary care access. Task force members provided extensive reflections on the critical role of primary care in coordinating care for complex patients, managing chronic diseases, and addressing healthcare affordability, noting that strong primary care is essential to achieving concierge-level care for all residents.

The meeting agenda included an update on the governor's healthcare affordability working group and a briefing from the insurance commissioner regarding updated regulations to streamline prior authorization practices. Staff from the HPC's Office of Patient Protection presented findings from the latest HPC data point series focused on health insurance claim denials in Massachusetts. The agenda also covered reviews of market transaction reviews and discussions on proposed draft regulations for implementing chapters 342 and 343 of the acts of 2024. Commissioners provided feedback on the urgency of affordability solutions, the importance of data-informed reform unconstrained by structural issues, and ensuring representation for the most financially vulnerable households, including low-income, black, Hispanic, and immigrant populations, in the working group discussions.

The meeting, the first of 2026, focused primarily on Statutory Deliverable Number Four, which concerns primary care payment reform. Key discussion points involved synthesizing previous conversations regarding the goals and principles for reforming primary care payment to better align reimbursement models with the four pillars of person-centered primary care. Goals identified include improving patient access and experience, enabling provider flexibility (e.g., for telehealth and extended hours), strengthening primary care capacity, supporting team-based care models, improving quality outcomes and equity, reducing administrative burden (including EMR requirements), and enhancing workforce stability. Principles discussed for design included shifting from fee-for-service to prospective capitated payments, ensuring alignment across payers, incorporating equity considerations like risk adjustment for social factors, and aligning payment reform with the established primary care spending target.

The meeting of the Workforce Workgroup focused on key areas contributing to administrative burden in primary care. The primary discussion centered on prior authorization (PA) and quality measurement. Key PA reform topics discussed included increasing transparency regarding services subject to PA, reporting denial rates and response times, standardizing electronic platforms, mandating a 24-hour response time, and 'gold carding' providers with high approval rates. The group also discussed a Rhode Island three-year pilot program prohibiting PA requirements for services ordered by primary care providers. Quality measurement discussions involved efforts to standardize and streamline measurement to avoid inconsistent reporting across payers. Attendees also mentioned credentialing issues and the absence of PA for generic medications as other areas of concern.