Baker Bill Demands More Money For Primary Care And Behavioral Health

Gov. Charlie Baker is igniting another round of health care debates in Massachusetts with a bill that would require all providers and insurers to boost spending in primary care and behavioral health, penalize excessive drug price increases and limit surprise emergency billing.

Health and Human Services Secretary Marylou Sudders says the bill builds on state laws that expanded access to care and controlled costs, and focuses on value — specifically in primary care and behavioral health.

"Over the years, we have invested in technological advances, but not invested as much in time and patient-centric primary care and behavioral health," Sudders said. "We believe if we want to improve health outcomes and lower costs in the long run, we need to invest in those services."

Many Massachusetts residents have a story about waiting a long time to find a primary care doctor or a counselor who is accepting new patients.

For example, in the Framingham area, the routine wait for a therapy appointment is eight to 12 weeks, said Martin Cohen, CEO of Metrowest Health Foundation.

"If I'm a 12 or 13 year old, that's a lifetime. We gotta do a better job freeing up access," said Cohen, who is also vice chair of the state's Health Policy Commission.

Cohen says he's optimistic that new spending requirements in Baker's bill would mean more substance use and mental health services within primary care, health centers and emergency rooms. But some insurers and hospitals say at first glance, the new requirement is not realistic.

Here's how it would work: Every hospital, physician group and insurer would tell a state agency how much they are spending on primary care and behavioral health this year. By 2023, spending in those two areas would have to increase by a total of 30%, and this shift would have to occur without raising health care costs overall. The state's loose cap on health care spending increases — which is 3.1% this year — would remain. Any provider or insurer that did not comply would be reviewed by state regulators who could impose an "improvement plan."

It will be difficult to demand a 30% increase in primary care and behavioral health from hospitals that are losing money or just breaking even. Behavioral health is often a money-losing service because insurance reimbursement rates are low — much lower than for cancer care or orthopedics, for example.

Sudders says that's why insurers are also required to increase spending for these basic services. That spending could include more providers as well as higher rates for primary care doctors, nurse practitioners, social workers, psychiatrists, addiction specialists and geriatric care.

"It is the appropriate role of government to say this is where we need to invest in health care in order to ensure that our population today and in the future receives the appropriate care that they need," Sudders said.

Massachusetts Association of Health Plans president Lora Pellegrini said in a statement that "primary care and behavioral health are the backbone of our health care delivery system. It is necessary that these investments are made within the confines of the state’s cost growth benchmark."

Baker's bill also proposes dozens of changes in other major areas.

To control drug prices, the proposal would require state regulators to review the price of any drug that costs more than $50,000 per patient. Drug makers whose products increased 2% faster than inflation within a year — like insulin — would be penalized. It would also eliminate gag rules that prevent pharmacists from telling patients if there is a cheaper drug option.

To protect consumers from surprise medical bills, the governor would limit the rates out-of-network providers could charge in emergencies, and restrict so-called "facility fees" that are sometimes added to outpatient medical bills.

To increase access to care, insurers would have to cover telemedicine, nurse practitioners would be able to write prescriptions without physician oversight, and the state would authorize mid-level dental providers, sometimes called dental therapists.

In this bill, Baker backs away from a controversial subject that helped derail major health care bills last year: closing hospital payment gaps. There's nothing in the proposal about a system that would cap payments to high cost hospitals or set a floor for payments to community hospitals.

"It felt like a blunt instrument," Sudders said. "What we really want to engage in is value-based health care. For us, value-based health care is investing in primary and behavioral health care."

The bill does create a fund that would likely benefit nine community hospitals, as well as community health centers that are not affiliated with teaching hospitals. It would be funded through a current assessment on hospitals as well as penalties paid by drug manufacturers with excessive price increases.

Many of the key groups that would be affected by Baker's proposals are still reviewing the details.

The state's largest health care consumer group, Health Care for All, says Baker's bill appeals to many important concerns.

"HCFA is especially appreciative of the inclusion of important provisions that reflect our own key priorities for consumers in the state: investing in primary care and behavioral health, addressing rising prescription drug costs, tackling out-of-network billing, improving provider directories, and expanding access to oral health care," said executive director Amy Rosenthal.

Steve Walsh, president of the Massachusetts Health and Hospital Association, said in a statement that the organization commends Baker's bill and the governor' focus on "addressing some of the commonwealth’s most challenging health care issues."

He cited oversight of the pharmaceutical industry, expanding telemedicine and adding Massachusetts to the Nurse Licensure Compact, which allows nurses to practice in other states without having to obtain additional licenses.

But Bob Coughlin, president of Massachusetts Biotechnology Council (MassBio), said in a statement that none of Baker's proposals would reduce direct consumer costs.

“The question for all policymakers should be: why are premiums and other patient costs increasing so much faster than the total healthcare expenditures growth rate?" Coughlin said. "Payers can no longer point to prescription drug spending when justifying their price hikes, as it grew at 3.6% last year after paying back more than $1.8 billion in rebates to insurers."