Massachusetts 2023-2024 Regular Session

Massachusetts Senate Bill S750 Compare Versions

Only one version of the bill is available at this time.

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1	1	1 of 1
2	2	SENATE DOCKET, NO. 2233 FILED ON: 1/20/2023
3	3	SENATE . . . . . . . . . . . . . . No. 750
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Cindy F. Friedman
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act relative to primary care for you.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :Cindy F. FriedmanFourth Middlesex 1 of 20
16	16	SENATE DOCKET, NO. 2233 FILED ON: 1/20/2023
17	17	SENATE . . . . . . . . . . . . . . No. 750
18	18	By Ms. Friedman, a petition (accompanied by bill, Senate, No. 750) of Cindy F. Friedman for
19	19	legislation relative to primary care for you. Health Care Financing.
20	20	[SIMILAR MATTER FILED IN PREVIOUS SESSION
21	21	SEE SENATE, NO. 770 OF 2021-2022.]
22	22	The Commonwealth of Massachusetts
23	23	_______________
24	24	In the One Hundred and Ninety-Third General Court
25	25	(2023-2024)
26	26	_______________
27	27	An Act relative to primary care for you.
28	28	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
29	29	of the same, as follows:
30	30	1 SECTION 1. Section 1 of chapter 6D of the General Laws, as appearing in the 2020
31	31	2Official Edition, is hereby amended by inserting after the definition of “After-hours care” the
32	32	3following definitions:-
33	33	4 “Aggregate primary care baseline expenditures”, the sum of all primary care
34	34	5expenditures, as defined by the center, in the commonwealth in the calendar year preceding the
35	35	6year in which the aggregate primary care expenditure target applies.
36	36	7 “Aggregate primary care expenditure target”, the targeted sum, set by the commission in
37	37	8section 9A, of all primary care expenditures, as defined by the center, in the commonwealth in
38	38	9the calendar year in which the aggregate primary care expenditure target applies. 2 of 20
39	39	10 SECTION 2. Said section 1 of said chapter 6D, as so appearing, is hereby further
40	40	11amended by inserting after the definition of “Physician” the following definitions:-
41	41	12 “Primary care baseline expenditures”, the sum of all primary care expenditures, as
42	42	13defined by the center, by or attributed to an individual health care entity in the calendar year
43	43	14preceding the year in which the primary care expenditure target applies.
44	44	15 “Primary care expenditure target”, the targeted sum, set by the commission in section 9A,
45	45	16of all primary care expenditures, as defined by the center, by or attributed to an individual health
46	46	17care entity in the calendar year in which the entity’s primary care expenditure target applies.
47	47	18 SECTION 3. Section 8 of said chapter 6D, as so appearing, is hereby amended by
48	48	19striking out subsection (a) and inserting in place thereof the following subsection:-
49	49	20 (a) Not later than October 1 of every year, the commission shall hold public hearings
50	50	21based on the report submitted by the center under section 16 of chapter 12C comparing the
51	51	22growth in total health care expenditures to the health care cost growth benchmark for the
52	52	23previous calendar year and comparing the growth in actual aggregate primary care expenditures
53	53	24for the previous calendar year to the aggregate primary care expenditure target. The hearings
54	54	25shall examine health care provider, provider organization and private and public health care
55	55	26payer costs, prices and cost trends, with particular attention to factors that contribute to cost
56	56	27growth within the commonwealth’s health care system and challenge the ability of the
57	57	28commonwealth’s health care system to meet the benchmark established under section 9 or the
58	58	29aggregate primary care expenditure target established under section 9A. 3 of 20
59	59	30 SECTION 4. Said section 8 of said chapter 6D, as so appearing, is hereby further
60	60	31amended by striking out, in line 94, the word “and” and inserting in place thereof the following
61	61	32words:- , including primary care expenditures, and.
62	62	33 SECTION 5. Said chapter 6D is hereby further amended by inserting after section 9 the
63	63	34following sections:-
64	64	35 Section 9A. (a) The commission- shall establish an aggregate primary care expenditure
65	65	36target for the commonwealth, which the commission shall prominently publish on its website.
66	66	37 (b) The commission shall establish the aggregate primary care expenditure target and the
67	67	38primary care expenditure target as follows:
68	68	39 (1) For the calendar year 2026, the aggregate primary care expenditure target and the
69	69	40primary care expenditure target shall be equal to 8 per cent of total health care expenditures in
70	70	41the commonwealth;
71	71	42 (2) For the calendar year 2027, the aggregate primary care expenditure target and the
72	72	43primary care expenditure target shall be equal to 10 per cent of total health care expenditures in
73	73	44the commonwealth;
74	74	45 (3) For the calendar year 2028, the aggregate primary care expenditure target and the
75	75	46primary care expenditure target shall be equal to 12 per cent of total health care expenditures in
76	76	47the commonwealth; and
77	77	48 (4) For calendar years 2029 and beyond, if the commission determines that an adjustment
78	78	49in the aggregate primary care expenditure target and the primary care expenditure target is
79	79	50reasonably warranted, the commission may recommend modification to such targets, provided, 4 of 20
80	80	51that such targets shall not be lower than 12 per cent of total health care expenditures in the
81	81	52commonwealth or higher than 15 per cent of total health care expenditures in the commonwealth.
82	82	53 (c) Prior to establishing the aggregate primary care expenditure target and the primary
83	83	54care expenditure target, the commission shall hold a public hearing. The public hearing shall be
84	84	55based on the report submitted by the center under section 16 of chapter 12C, comparing the
85	85	56actual aggregate expenditures on primary care services to the aggregate primary care expenditure
86	86	57target, any other data submitted by the center and such other pertinent information or data as may
87	87	58be available to the commission. The hearings shall examine the performance of health care
88	88	59entities in meeting the primary care expenditure target and the commonwealth’s health care
89	89	60system in meeting the aggregate primary care expenditure target. The commission shall provide
90	90	61public notice of the hearing at least 45 days prior to the date of the hearing, including notice to
91	91	62the joint committee on health care financing. The joint committee on health care financing may
92	92	63participate in the hearing. The commission shall identify as witnesses for the public hearing a
93	93	64representative sample of providers, provider organizations, payers and such other interested
94	94	65parties as the commission may determine. Any other interested parties may testify at the hearing.
95	95	66 (d) Any recommendation of the commission to modify the aggregate primary care
96	96	67expenditure target and the primary care expenditure target under paragraph (4) of subsection (b)
97	97	68shall be approved by a two thirds vote of the board.
98	98	69 Section 9B. (a) As used in this section, the following words shall have the following
99	99	70meanings, unless the context clearly requires otherwise:
100	100	71 “Primary care provider”, a health care professional qualified to provide general medical
101	101	72care for common health care problems, who supervises, coordinates, prescribes or otherwise 5 of 20
102	102	73provides or proposes health care services, initiates referrals for specialist care and maintains
103	103	74continuity of care within the scope of practice; provided, that a “primary care provider” shall
104	104	75include a provider organization that provides primary care services in the commonwealth.
105	105	76 “Primary care service”, a service provided by a primary care provider.
106	106	77 (b) There shall be within the commission a primary care board, which shall consist of 19
107	107	78members: the executive director of the commission or a designee, who shall serve as chair; the
108	108	79secretary of the executive office of health and human services or a designee; the senate chair of
109	109	80the joint committee on health care financing or a designee; the house chair of the joint committee
110	110	81on health care financing or a designee; 2 members to be appointed by the governor, 1 of whom
111	111	82shall be a primary care patient in the commonwealth and 1 of whom shall be the parent of a
112	112	83pediatric primary care patient in the commonwealth; the commissioner of insurance or a
113	113	84designee; 1 member from the Massachusetts Primary Care Alliance for Patients; 1 member from
114	114	85the Massachusetts Academy of Family Physicians; 1 member from the Massachusetts Chapter of
115	115	86the American Academy of Pediatrics; 1 member from the Massachusetts Chapter of the
116	116	87American College of Physicians; 1 member from the Massachusetts League of Community
117	117	88Health Centers; 1 member from Health Care For All Massachusetts; 1 member from the
118	118	89Massachusetts Medical Society; 1 member from the Association for Behavioral Healthcare; 1
119	119	90member from the Massachusetts Association of Physician Assistants; 1 member from the
120	120	91Massachusetts Coalition of Nurse Practitioners; 1 member from the Massachusetts Association
121	121	92of Health Plans; and 1 member from Blue Cross Blue Shield of Massachusetts. 6 of 20
122	122	93 All appointments shall serve a term of 3 years, but a person appointed to fill a vacancy
123	123	94shall serve only for the unexpired term. An appointed member of the board shall be eligible for
124	124	95reappointment. The members shall be appointed not later than 60 days after a vacancy.
125	125	96 (c) The board shall develop and recommend a primary care prospective payment model,
126	126	97to be implemented by the commission, that allows a primary care provider in the commonwealth
127	127	98to opt in to receiving a monthly lump sum payment for all primary care services delivered. Any
128	128	99recommendation of the board to establish a primary care prospective payment model shall be
129	129	100approved by a two thirds vote of the commission’s board established in section 2; provided, that
130	130	101the recommended payment model shall comply with the requirements of this section.
131	131	102 (d) The primary care prospective payment model shall include a baseline monthly per
132	132	103patient payment, which shall be based on the historical monthly primary care spending per
133	133	104patient at the primary care provider or provider organization level, the historical monthly primary
134	134	105care spending per patient statewide, the primary care expenditure data published in the center’s
135	135	106annual report under section 16 of chapter 12C, and any other factors deemed relevant by the
136	136	107board. The baseline monthly per patient payment shall be adjusted based on:
137	137	108 (1) a primary care provider’s adoption of the primary care transformers established in
138	138	109subsection (e);
139	139	110 (2) the quality of patient care delivered by a primary care provider, as described in
140	140	111subsection (f); and
141	141	112 (3) the clinical and social risk of the primary care provider’s patient panel, as described in
142	142	113subsection (g). 7 of 20
143	143	114 (e) The primary care prospective payment model shall include a list of primary care
144	144	115transformers, created by the board, that, if adopted by a primary care provider, shall increase a
145	145	116primary care provider’s baseline monthly per patient payment, as determined by the board. A
146	146	117primary care transformer shall be an evidence-informed or evidence-based primary care service
147	147	118that improves primary care quality, increases primary care access, enhances a patient’s primary
148	148	119care experience, or promotes health equity in primary care. A primary care transformer shall
149	149	120include, but not be limited to: (i) employing community health workers or health coaches as part
150	150	121of the primary care team; (ii) investing in social determinants of health; (iii) collaborating with
151	151	122primary care-based clinical pharmacists; (iv) integrating behavioral health care with primary
152	152	123care; (v) offering substance use disorder treatment, including medication-assisted treatment,
153	153	124telehealth services, including telehealth consultations with specialists, medical interpreter
154	154	125services, home care, patient advisory groups, and group visits; (vi) using clinician optimization
155	155	126programs to reduce documentation burden, including, but not limited to, medical scribes and
156	156	127ambient voice technology; (vii) investing in care management, including employing social
157	157	128workers to help manage the care for patients with complicated health needs; (viii) establishing
158	158	129systems to facilitate end of life care planning and palliative care; (ix) developing systems to
159	159	130evaluate patient population health to help determine which preventative medicine interventions
160	160	131require patient outreach; (x) offering walk-in or same-day care appointments or extended hours
161	161	132of availability; and (xi) any other primary care service deemed relevant by the board.
162	162	133 The board shall assign a value to each primary care transformer based on the strength of
163	163	134evidence that the transformer will: (i) improve patient health; (ii) enhance patient experience;
164	164	135(iii) improve clinician experience, including reducing administrative burden; (iv) decrease total
165	165	136medical expense; and (iv) promote health equity. Assigned values may account for the total time 8 of 20
166	166	137and expense required to implement the transformer by a primary care provider. When assigning a
167	167	138value to each primary care transformer, the board shall consider the primary care sub-capitation
168	168	139and tiering system established in the MassHealth section 1115 demonstration waiver. The board
169	169	140shall review the primary care transformers, at least every 3 years, to determine the
170	170	141appropriateness of each transformer, its value, and whether additional transformers are
171	171	142necessary.
172	172	143 A primary care provider shall only be granted credit for a primary care transformer if the
173	173	144primary care provider attests to meeting the transformer’s requirements.
174	174	145 (f) The board shall consider a primary care provider’s performance on patient care quality
175	175	146measures when establishing the baseline monthly per patient payment under subsection (d).
176	176	147Patient care quality measures shall include, but not be limited to, established measures related to:
177	177	148(i) care continuity, comprehensiveness, and coordination; (ii) patient access to primary care; and
178	178	149(iii) patient experience. Each quality measure shall be patient-centered, appropriate for a primary
179	179	150care setting, and supported by peer-reviewed, evidence-based research that the measure is
180	180	151actionable and that its use will lead to improvements in patient health. The board shall establish
181	181	152not more than 10 quality measures and shall require a primary care provider to only adopt 5 of
182	182	153the quality measures, which shall include at least 2 measures of patient experience and 1 person-
183	183	154centered primary care measure.
184	184	155 (g) The board shall consider the clinical and social complexity of a primary care
185	185	156provider’s patient panel when establishing the baseline monthly per patient payment under
186	186	157subsection (d). Measures of the clinical and social complexity of a patient panel shall include,
187	187	158but not be limited to, measures that promote health equity and measures such as MassHealth’s 9 of 20
188	188	159Neighborhood Stress Score. The board shall, to the extent possible, use measures of the clinical
189	189	160and social complexity of a patient panel in a manner that minimizes opportunities to artificially
190	190	161increase the clinical and social complexity of a patient panel.
191	191	162 (h) The board may establish a primary care provider tiering structure based on the type
192	192	163and number of primary care transformers adopted by a primary care provider. This tiering
193	193	164structure may be used by the board to determine the baseline monthly per patient payment. When
194	194	165establishing the tiering structure, the board shall consider the primary care sub-capitation and
195	195	166tiering system established in the MassHealth section 1115 demonstration waiver.
196	196	167 (i) The primary care prospective payment model shall include a voluntary opt-in process
197	197	168that allows a primary care provider in the commonwealth to opt in to the payment model.
198	198	169 (j) The primary care prospective payment model shall require at least 95 per cent of
199	199	170primary care payments made under the model to go directly to primary care providers for the
200	200	171delivery of primary care services in the commonwealth.
201	201	172 (k) Health insurance coverage for a patient’s primary care services delivered by a primary
202	202	173care provider participating in the primary care prospective payment model shall not be subject to
203	203	174any cost-sharing, including co-payments and co-insurance, and shall not be subject to any
204	204	175deductible.
205	205	176 (l) Any carrier that provides health insurance coverage to a patient receiving primary care
206	206	177services from a primary care provider participating in the primary care prospective payment
207	207	178model shall comply with the requirements of said payment model, as described in this section. 10 of 20
208	208	179 (m) Payments made to primary care providers under the primary care prospective
209	209	180payment model shall be included in the medical loss ratio calculated under section 6 of chapter
210	210	181176J.
211	211	182 (n) Payments made to primary care providers under the primary care prospective payment
212	212	183model shall be primary care expenditures for a primary care provider and a carrier for purposes
213	213	184of complying with the primary care expenditure target established in section 9A.
214	214	185 (o) A Federally qualified community health center may receive a prospective monthly
215	215	186payment for primary care services delivered to their commercially-insured patients, as
216	216	187determined by the board. The payment shall be no less than what the federally qualified
217	217	188community health center would receive through the Prospective Payment System rate.
218	218	189 (p) The board shall establish an attestation, public reporting, and audit process for
219	219	190primary care providers that opt in to the primary care prospective payment model to ensure
220	220	191compliance with this section. A primary care provider that does not comply with the
221	221	192requirements of this section may be prohibited from participating in the primary care prospective
222	222	193payment model until such noncompliance is rectified.
223	223	194 (q) The board shall review and revise the primary care prospective payment model as
224	224	195necessary. Annually, the board shall submit a report summarizing it activities to the chair of the
225	225	196commission’s board, the clerks of the house of representatives and senate, the chairs of the house
226	226	197and senate committees on ways and means, and the chairs of the joint committee on health care
227	227	198financing.
228	228	199 (r) The commission shall promulgate rules and regulations necessary to implement this
229	229	200section. 11 of 20
230	230	201 SECTION 6. Said chapter 6D, as so appearing, is hereby further amended by inserting
231	231	202after section 10 the following section:-
232	232	203 Section 10A. (a) For the purposes of this section, “health care entity” shall mean any
233	233	204entity identified by the center under section 18 of chapter 12C.
234	234	205 (b) The commission shall provide notice to all health care entities that have been
235	235	206identified by the center under section 18 of chapter 12C for failure to meet the primary care
236	236	207expenditure target. Such notice shall state that the center may analyze the performance of
237	237	208individual health care entities in meeting the primary care expenditure target and, beginning in
238	238	209calendar year 2025, the commission may require certain actions, as established in this section,
239	239	210from health care entities so identified.
240	240	211 (c) In addition to the notice provided under subsection (b), the commission may require
241	241	212any health care entity that is identified by the center under section 18 of chapter 12C for failure
242	242	213to meet the primary care expenditure target to file and implement a performance improvement
243	243	214plan. The commission shall provide written notice to such health care entity that they are
244	244	215required to file a performance improvement plan. Within 45 days of receipt of such written
245	245	216notice, the health care entity shall either:
246	246	217 (1) file a performance improvement plan with the commission; or
247	247	218 (2) file an application with the commission to waive or extend the requirement to file a
248	248	219performance improvement plan.
249	249	220 (d) The health care entity may file any documentation or supporting evidence with the
250	250	221commission to support the health care entity’s application to waive or extend the requirement to 12 of 20
251	251	222file a performance improvement plan. The commission shall require the health care entity to
252	252	223submit any other relevant information it deems necessary in considering the waiver or extension
253	253	224application; provided, however, that such information shall be made public at the discretion of
254	254	225the commission.
255	255	226 (e) The commission may waive or delay the requirement for a health care entity to file a
256	256	227performance improvement plan in response to a waiver or extension request filed under
257	257	228subsection (c) in light of all information received from the health care entity, based on a
258	258	229consideration of the following factors: (1) the primary care baseline expenditures, costs, price
259	259	230and utilization trends of the health care entity over time, and any demonstrated improvement to
260	260	231increase the proportion of primary care expenditures; (2) any ongoing strategies or investments
261	261	232that the health care entity is implementing to invest in or expand access to primary care services;
262	262	233(3) whether the factors that led to the inability of the health care entity to meet the primary care
263	263	234expenditure target can reasonably be considered to be unanticipated and outside of the control of
264	264	235the entity; provided, that such factors may include, but shall not be limited to, market dynamics,
265	265	236technological changes and other drivers of non-primary care spending such as pharmaceutical
266	266	237and medical devices expenses; (4) the overall financial condition of the health care entity; and
267	267	238(5) any other factors the commission considers relevant.
268	268	239 (f) If the commission declines to waive or extend the requirement for the health care
269	269	240entity to file a performance improvement plan, the commission shall provide written notice to the
270	270	241health care entity that its application for a waiver or extension was denied and the health care
271	271	242entity shall file a performance improvement plan. 13 of 20
272	272	243 (g) The commission shall provide the department of public health any notice requiring a
273	273	244health care entity to file and implement a performance improvement plan pursuant to this
274	274	245section. In the event a health care entity required to file a performance improvement plan under
275	275	246this section submits an application for a notice of determination of need under section 25C or 51
276	276	247of chapter 111, the notice of the commission requiring the health care entity to file and
277	277	248implement a performance improvement plan pursuant to this section shall be considered part of
278	278	249the written record pursuant to said section 25C of chapter 111.
279	279	250 (h) A health care entity shall file a performance improvement plan: (1) within 45 days of
280	280	251receipt of a notice under subsection (c); (2) if the health care entity has requested a waiver or
281	281	252extension, within 45 days of receipt of a notice that such waiver or extension has been denied; or
282	282	253(3) if the health care entity is granted an extension, on the date given on such extension. The
283	283	254performance improvement plan shall identify specific strategies, adjustments and action steps the
284	284	255entity proposes to implement to increase the proportion of primary care expenditures. The
285	285	256proposed performance improvement plan shall include specific identifiable and measurable
286	286	257expected outcomes and a timetable for implementation.
287	287	258 (i) The commission shall approve any performance improvement plan that it determines
288	288	259is reasonably likely to address the underlying cause of the entity’s inability to meet the primary
289	289	260care expenditure target and has a reasonable expectation for successful implementation.
290	290	261 (j) If the board determines that the performance improvement plan is unacceptable or
291	291	262incomplete, the commission may provide consultation on the criteria that have not been met and
292	292	263may allow an additional time period, up to 30 calendar days, for resubmission. 14 of 20
293	293	264 (k) Upon approval of the proposed performance improvement plan, the commission shall
294	294	265notify the health care entity to begin immediate implementation of the performance improvement
295	295	266plan. Public notice shall be provided by the commission on its website, identifying that the health
296	296	267care entity is implementing a performance improvement plan. All health care entities
297	297	268implementing an approved performance improvement plan shall be subject to additional
298	298	269reporting requirements and compliance monitoring, as determined by the commission. The
299	299	270commission shall provide assistance to the health care entity in the successful implementation of
300	300	271the performance improvement plan.
301	301	272 (l) All health care entities shall, in good faith, work to implement the performance
302	302	273improvement plan. At any point during the implementation of the performance improvement
303	303	274plan the health care entity may file amendments to the performance improvement plan, subject to
304	304	275approval of the commission.
305	305	276 (m) At the conclusion of the timetable established in the performance improvement plan,
306	306	277the health care entity shall report to the commission regarding the outcome of the performance
307	307	278improvement plan. If the performance improvement plan was found to be unsuccessful, the
308	308	279commission shall either: (1) extend the implementation timetable of the existing performance
309	309	280improvement plan; (2) approve amendments to the performance improvement plan as proposed
310	310	281by the health care entity; (3) require the health care entity to submit a new performance
311	311	282improvement plan under subsection (c); or (4) waive or delay the requirement to file any
312	312	283additional performance improvement plans.
313	313	284 (n) Upon the successful completion of the performance improvement plan, the identity of
314	314	285the health care entity shall be removed from the commission’s website. 15 of 20
315	315	286 (o) The commission may submit a recommendation for proposed legislation to the joint
316	316	287committee on health care financing if the commission determines that further legislative
317	317	288authority is needed to achieve the health care quality and spending sustainability objectives of
318	318	289section 9A, assist health care entities with the implementation of performance improvement
319	319	290plans or otherwise ensure compliance with the provisions of this section.
320	320	291 (p) If the commission determines that a health care entity has: (1) willfully neglected to
321	321	292file a performance improvement plan with the commission by the time required in subsection (h);
322	322	293(2) failed to file an acceptable performance improvement plan in good faith with the
323	323	294commission; (3) failed to implement the performance improvement plan in good faith; or (4)
324	324	295knowingly failed to provide information required by this section to the commission or that
325	325	296knowingly falsifies the same, the commission may assess a civil penalty to the health care entity
326	326	297of not more than $500,000. The commission shall seek to promote compliance with this section
327	327	298and shall only impose a civil penalty as a last resort.
328	328	299 (q) The commission shall promulgate regulations necessary to implement this section.
329	329	300 (r) Nothing in this section shall be construed as affecting or limiting the applicability of
330	330	301the health care cost growth benchmark established under section 9, and the obligations of a
331	331	302health care entity thereto.
332	332	303 SECTION 7. Section 16 of chapter 12C of the General Laws, as so appearing in the 2020
333	333	304Official Edition, is hereby amended by striking out subsection (a) and inserting in place thereof
334	334	305the following subsection:-
335	335	306 (a) The center shall publish an annual report based on the information submitted under
336	336	307this chapter concerning health care provider, provider organization and private and public health 16 of 20
337	337	308care payer costs and cost trends, section 13 of chapter 6D relative to market power reviews and
338	338	309section 15 relative to quality data. The center shall compare the costs and cost trends with the
339	339	310health care cost growth benchmark established by the health policy commission under section 9
340	340	311of chapter 6D, analyzed by regions of the commonwealth, and shall compare the costs, cost
341	341	312trends, and expenditures with the aggregate primary care expenditure target established under
342	342	313section 9A of chapter 6D, and shall detail: (1) baseline information about cost, price, quality,
343	343	314utilization and market power in the commonwealth's health care system; (2) cost growth trends
344	344	315for care provided within and outside of accountable care organizations and patient-centered
345	345	316medical homes; (3) cost growth trends by provider sector, including but not limited to, hospitals,
346	346	317hospital systems, non-acute providers, pharmaceuticals, medical devices and durable medical
347	347	318equipment; provided, however, that any detailed cost growth trend in the pharmaceutical sector
348	348	319shall consider the effect of drug rebates and other price concessions in the aggregate without
349	349	320disclosure of any product or manufacturer-specific rebate or price concession information, and
350	350	321without limiting or otherwise affecting the confidential or proprietary nature of any rebate or
351	351	322price concession agreement; (4) factors that contribute to cost growth within the
352	352	323commonwealth's health care system and to the relationship between provider costs and payer
353	353	324premium rates; (5) primary care expenditure trends as compared to the aggregate primary care
354	354	325baseline expenditures, as defined in section 1 said chapter 6D; (6) the proportion of health care
355	355	326expenditures reimbursed under fee-for-service and alternative payment methodologies; (7) the
356	356	327impact of health care payment and delivery reform efforts on health care costs including, but not
357	357	328limited to, the development of limited and tiered networks, increased price transparency,
358	358	329increased utilization of electronic medical records and other health technology; (8) the impact of
359	359	330any assessments including, but not limited to, the health system benefit surcharge collected under 17 of 20
360	360	331section 68 of chapter 118E, on health insurance premiums; (9) trends in utilization of
361	361	332unnecessary or duplicative services, with particular emphasis on imaging and other high-cost
362	362	333services; (10) the prevalence and trends in adoption of alternative payment methodologies and
363	363	334impact of alternative payment methodologies on overall health care spending, insurance
364	364	335premiums and provider rates; (11) the development and status of provider organizations in the
365	365	336commonwealth including, but not limited to, acquisitions, mergers, consolidations and any
366	366	337evidence of excess consolidation or anti-competitive behavior by provider organizations; (12) the
367	367	338impact of health care payment and delivery reform on the quality of care delivered in the
368	368	339commonwealth; and (13) costs, cost trends, price, quality, utilization and patient outcomes
369	369	340related to primary care services.
370	370	341 SECTION 8. Said section 16 of said chapter 12C, as so appearing, is hereby further
371	371	342amended by adding the following subsections:-
372	372	343 (d) The center shall publish the aggregate primary care baseline expenditures in its annual
373	373	344report.
374	374	345 (e) The center, in consultation with the commission, shall determine the primary care
375	375	346baseline expenditures for individual health care entities and shall report to each health care entity
376	376	347its respective baseline expenditures annually, by October 1.
377	377	348 SECTION 9. Said chapter 12C, as so appearing, is hereby further amended by striking
378	378	349out section 18 and inserting in place thereof the following section:-
379	379	350 Section 18. The center shall perform ongoing analysis of data it receives under this
380	380	351chapter to identify any payers, providers or provider organizations: (i) whose increase in health
381	381	352status adjusted total medical expense is considered excessive and who threaten the ability of the 18 of 20
382	382	353state to meet the health care cost growth benchmark established by the health care finance and
383	383	354policy commission under section 10 of chapter 6D; or (ii) whose expenditures fail to meet the
384	384	355primary care expenditure target under section 9A of chapter 6D. The center shall confidentially
385	385	356provide a list of the payers, providers and provider organizations to the health policy commission
386	386	357such that the commission may pursue further action under sections 10 and 10A of chapter 6D.
387	387	358 SECTION 10. Chapter 29 of the General Laws, as appearing in the 2020 Official Edition,
388	388	359is hereby amended by inserting after section 2OOOOO the following section:-
389	389	360 Section 2PPPPP. (a) As used in this section, the following words shall have the following
390	390	361meanings unless the context clearly requires otherwise:
391	391	362 “Carrier”, an insurer licensed or otherwise authorized to transact accident or health
392	392	363insurance under chapter 175; a nonprofit hospital service corporation organized under chapter
393	393	364176A; a nonprofit medical service corporation organized under chapter 176B; a health
394	394	365maintenance organization organized under chapter 176G; and an organization entering into a
395	395	366preferred provider arrangement under chapter 176I; provided, that this shall not include an
396	396	367employer purchasing coverage or acting on behalf of its employees or the employees of 1 or
397	397	368more subsidiaries or affiliated corporations of the employer; provided that, unless otherwise
398	398	369noted, the term ''carrier'' shall not include any entity to the extent it offers a policy, certificate or
399	399	370contract that provides coverage solely for dental care services or visions care services.
400	400	371 “Provider”, any person, corporation, partnership, governmental unit, state institution or
401	401	372any other entity qualified under the laws of the commonwealth to perform or provide health care
402	402	373services. 19 of 20
403	403	374 “Provider organization”, any corporation, partnership, business trust, association or
404	404	375organized group of persons, which is in the business of health care delivery or management,
405	405	376whether incorporated or not that represents 1 or more health care providers in contracting with
406	406	377carriers for the payments of heath care services; provided, that ''provider organization'' shall
407	407	378include, but not be limited to, physician organizations, physician-hospital organizations,
408	408	379independent practice associations, provider networks, accountable care organizations and any
409	409	380other organization that contracts with carriers for payment for health care services.
410	410	381 (b) There is hereby established and set up on the books of the commonwealth a separate
411	411	382fund to be known as the primary care trust fund for the purpose of providing the prospective
412	412	383monthly payments to primary care providers participating in the primary care prospective
413	413	384payment model established in section 9B of chapter 6D. The fund shall be administered by the
414	414	385health policy commission. There shall be credited to the fund: (i) an annual assessment on
415	415	386carriers, providers, provider organizations, and for profit non-traditional healthcare corporations
416	416	387and entities that provide, as part of a larger business model, primary care services in the
417	417	388commonwealth, including, but not limited to, retailers, pharmacy benefits manager, and private
418	418	389equity firms, in an amount and manner determined by the commission; (ii) revenue from
419	419	390appropriations or other money authorized by the general court and specifically designated to be
420	420	391credited to the fund; and (iii) interest earned on such revenues. Amounts credited to the fund
421	421	392shall not be subject to further appropriation and any money remaining in the fund at the end of a
422	422	393fiscal year shall not revert to the General Fund.
423	423	394 Funds may be used for scientific evaluation of the primary care prospective payment
424	424	395model established under section 9B of chapter 6D. 20 of 20
425	425	396 (c) Not later than the first day of each month, the commission shall ensure that the
426	426	397primary care trust fund transfers the necessary amount to cover the payments to primary care
427	427	398provers required by the primary care prospective payment model established in section 9B of
428	428	399chapter 6D.
429	429	400 (d) Annually, not later than October 1, the commission shall report to the clerks of the
430	430	401house of representatives and senate, the chairs of the joint committee on health care financing,
431	431	402and the chairs of the house and senate committees on ways and means on the fund’s activity. The
432	432	403report shall include, but not be limited to: (i) the source and amount of funds received; (ii) total
433	433	404expenditures; and (iii) anticipated revenue and expenditure projections for the next calendar year.
434	434	405 SECTION 11. The regulations required by subsection (r) of section 9B of chapter 6D of
435	435	406the General Laws shall be promulgated not later than January 1, 2025.
436	436	407 SECTION 12. Subsection (e) of section 16 of chapter 12C of the General Laws shall take
437	437	408effect October 1, 2025.
438	438	409 SECTION 13. The primary care board, established in section 9B of chapter 6D of the
439	439	410General Laws, shall convene its first meeting not later than March 1, 2025, and shall develop and
440	440	411recommend the implementation of a primary care prospective payment model to the health
441	441	412policy commission, established in said chapter 6D, not later than January 1, 2026.