The following was prepared by the UMass Center for Integrated Primary Care, for more information about CIPC courses for behavioral clinicians, physicians, and other members of the primary care team visit: www.umassmed.edu/cipc
Massachusetts is considering legislation called Primary Care for You (PC4YOU) that could have a national impact as the country deals with the challenges of access to primary care.
The PC4YOU legislation proposes to increase primary care spending to about 15% of overall health care expenditures by 2029 by requiring all commercial payers to offer a prospective, per patient per month payment to primary care practices that opt-in.
Daniel Mullin, PsyD MPH, director of the Center for Integrated Primary Care (CIPC), began his involvement with primary care transformation more than a decade ago during the early stages of the Patient-Centered Medical Home (PCMH) movement. At the time, there was a lot of excitement about the potential of PCMH to revitalize primary care, but over the years, it became evident that the financial changes promised as part of the PCMH were never realized. Those frustrations increasingly led advocates in Massachusetts to push for state-level policy changes to reshape how primary care is funded relative to the rest of the healthcare system.
Dan was alerted to the PC4YOU legislation by mentors and colleagues who are leaders in Family Medicine in Massachusetts. For over five years, an email thread, which later became a listserv, has allowed Massachusetts colleagues to voice their concerns, observations, and hopes regarding the state of primary care practice.
What is different about PC4YOU?
The PC4YOU legislation is broad and ambitious. One of its strengths lies in encouraging practices to customize their services to meet community needs. Among the key areas of focus are "transformers"—essential innovations like integrating behavioral health, which practices are encouraged to adopt.
These transformers could also include investing in practice-based care management and addiction treatment services. To incentivize these enhancements, the legislation outlines a process for increasing monthly per-patient payments for practices that implement these changes. By doing so, it aims to ensure that practices are not only financially supported but also better equipped to provide comprehensive care tailored to their patient's needs.
The transformers described in this legislation strike a balance between allowing practices to tailor their approach to primary care while committing themselves to team-based, whole-person care. Whole-person care embodies the realization of the biopsychosocial model first articulated by George Engel, MD, in the 1970s. The legislation recognizes that a team of behavioral health clinicians, pharmacists, care managers, and advanced practice providers is essential to supporting primary care physicians' efforts to address prevention, along with both acute and chronic care.
Past Challenges in Implementing Behavioral Health Aspects
In the past, the per-member, per-month (PMPM) payments in Accountable Care Organizations (ACOs) have not flowed to primary care practices to expand additional staff and clinicians to provide care. Instead, the ACOs consume much of the PMPM revenue with spending on project management, data analysis, and performance management work. Ten years ago, when many were advocating for PMPM payment models to support team-based primary care, it appeared that programs were not adequately designed to ensure these new payments would increase the supply of practice-based resources. This oversight has led to the emergence of massive ACO-level bureaucracies that consume revenue urgently needed by primary care practices to meet the needs of their patients.
Reflecting on the need for practice-level, locally-led teams, Dr. Mullin said,
“It is critical that these teams are managed at the practice level. You cannot have a high-functioning primary care team when the doctors work for the medical group, behavioral health clinicians report to psychiatry, the care managers report to the ACO, and the nurses report to the hospital. This would be like trying to run a basketball team when each of the players on the court were being directed by a different coach. It is a silly way to build a team; you certainly aren’t going to win any championships when you organize a team this way.”
Closing the Gap in Primary Care Spending
This legislation has been advanced by a core group of leaders in primary care, including Wayne Altman, MD, Professor and Chair of Family Medicine at Tufts University School of Medicine. Altman founded the MA Primary Care Alliance for Patients (MAPCAP). Altman states, “Primary Care has a triple superpower: better population health and increased equity, all at a lower overall cost.” We must double our investment in Primary Care to give patients the access to high quality care that they deserve.” There is also a broad network of colleagues, including Dan Mullin, who have participated in town halls and met with legislators to provide input on this legislation. Particularly within the field of Family Medicine, many passionate physicians advocate forcefully for the centrality of behavioral healthcare to primary care. Many of these physicians have practiced for decades alongside behavioral health colleagues who care for their patients. Ron Adler, MD, President of the Massachusetts Academy of Family Physicians, shares, “We know that a high-functioning team delivering comprehensive primary care services – including integrated behavioral health – can improve quality of care and access, while reducing costs, promoting equity, and improving quality of work-life, thus reducing burnout and making primary care more sustainable. In fact, this has been termed the Quintuple Aim, and greater investment in primary care is an obvious way to achieve it, and we see the proposed legislation as a key pathway for this transformative change.”
During the 2023-2024 Massachusetts legislative session, a version of the bill sought to increase annual spending on primary care from 7.5% of total healthcare spending in 2026 to 15% in 2027. Unfortunately, while this legislation was given a favorable vote in committee, it did not receive a vote by the full Senate or House. The bill has been reintroduced in the 2025-2026 legislative session with similarly ambitious targets in primary care spending.
Shaping the Future of Primary Care and Behavioral Health
A modern, cost-effective healthcare system depends on a robust, well-funded primary care system. Primary care can be thought of as the basic infrastructure for the health system. Just as small businesses cannot function without electricity, high-speed internet, and transportation, healthcare systems cannot operate adequately without primary care. When primary care functions well, specialists in the health system benefit, and so do communities.
While the PC4YOU legislation was not passed during the most recent legislative session, the Massachusetts legislature did approve creation of a Primary Care Task Force, “to study and make recommendations to improve PC access, delivery, and financial sustainability.” This task force will include 25 members, including one Behavioral Health representative with expertise in Primary Care. The legislation grants this board the authority to “develop and recommend a primary care prospective payment model, to be implemented by the commission, that allows a primary care provider in the commonwealth to opt into receiving a monthly lump sum payment for all primary care services delivered.”
The PC4YOU legislation marks a pivotal step toward creating a more equitable, efficient, and integrated primary care system. By increasing funding for primary care and incentivizing the inclusion of essential services like behavioral health, this legislation aims to support practices in delivering comprehensive, whole-person care that meets the evolving needs of their communities. Although setbacks occurred in the 2023-2024 legislative session, the continued advocacy from primary care leaders, including Dan Mullin and his colleagues, signals optimism for future success.
The path forward may be challenging, but with sustained support and collaboration, Massachusetts has the potential to lead the way in reshaping how primary care is funded and delivered, ultimately benefiting both patients and providers. As the focus turns toward the creation of the Primary Care Board, the future of primary care, and its integration with behavioral health, looks promising. The groundwork laid today could transform the landscape of healthcare for years to come in Massachusetts and across the country.
To learn more about the PC4YOU legislation you can find a description here in the journal Health Affairs:
https://www.healthaffairs.org/content/forefront/value-based-primary-care-model-doubles-primary-care-investment
You can also find the PC4YOU website here:
https://sites.tufts.edu/chsp/2023/05/18/primary-care-for-you-pc4you/
