Massachusetts Legislation Addresses Primary Care Workforce Issues

Massachusetts has enacted a sweeping health care measure designed to strengthen the state's primary care infrastructure by addressing primary care workforce shortages while bolstering an existing health care plan.

Gov. Deval Patrick signed S.B. 2863 (55-page PDF; About PDFs) into law on Aug. 10. The measure gives the state the authority to establish a medical home demonstration project and creates a loan forgiveness program for physicians and nurses who agree to practice primary care in medically underserved areas. In addition, the law establishes an affordable housing pilot for health care professionals who practice in underserved areas and provides greater tuition incentives for University of Massachusetts medical students who agree to practice primary care in the state for four years.

The measure also sets up a health care workforce center within the Massachusetts Department of Public Health to improve access to health care services in the state. The legislation requires that the Massachusetts AFP have a seat on the center's advisory committee to help it develop short-term and long-term policies to address workforce shortages in Massachusetts.

"This bill recognizes the important role primary care physicians play in the delivery of health care," said Dennis Dimitri, M.D., of Worcester, Mass., president of the Massachusetts AFP and vice chair for clinical services in the family medicine department at the University of Massachusetts Medical School. "It will bring about some changes that hopefully will increase the number of students interested in primary care careers by making (primary care) more attractive and viable for practitioners in Massachusetts."

The enactment of S.B. 2863 represents the second time in the past 18 months that the Massachusetts legislature has passed a comprehensive health care bill. In April 2006, Massachusetts became the first state in the country to enact a law requiring all residents to carry health insurance.

The Massachusetts Health Care Reform Plan dramatically reduced the number of uninsured residents in the state, cutting the uninsured rate to about 5 percent by bringing more than 300,000 previously uninsured people into the health care system. But the health care plan has created a growing demand for primary care health services that cannot be met by the state's existing supply of health care practitioners. Without an adequate supply of primary care providers, the plan cannot guarantee timely access to care, creating a gap between coverage and the actual provision of services.

The recently passed legislation is an attempt to address access-to-care issues by strengthening the system itself though the establishment of the patient-centered medical home and by creating a robust primary care workforce, particularly in rural areas.

"It is really important that we expand access to primary care in a variety of ways to try and make sure people can get care when they need it and not wait until it is a crisis or utilize services designed for a crisis," said state Sen. Richard Moore, D-Uxbridge, a sponsor of the legislation.

Dimitri, meanwhile, described the legislation as a "win for family physicians in our state." Certain provisions of the law still need to be flushed out, however. For example, the legislation authorizes MassHealth to develop a medical home pilot project in conjunction with the state's Health Care Workforce and the Massachusetts AFP, but it is not clear how the medical home pilot will be structured, how many practices it will involve or how long it will last. The project itself is "subject to (funds) appropriation," according to the bill, but Karen Brenke, EVP of the Massachusetts AFP, said the pilot will go forward.

"No state is having a good budget year because of the economy," said Moore, "but we will be focusing on the (medical home), particularly for chronic illnesses where it makes sense to better manage a patient's care."

The Massachusetts AFP, meanwhile, has raised concerns about other provisions of the legislation, noting, for example, that the bill directs commercial insurers to list nurse practitioners as primary care providers. The bill does not permit independent practice by nurse practitioners and does not expand scope of practice for these designated providers, however.

"There are those who are concerned that this is an attempt to replace family physicians and other primary care doctors," said Dimitri, "But in Massachusetts, the regulations still will require that nurses practicing in this expanded role do so in collaboration with a physician."

Another bill provision limits gifts by pharmaceutical companies and device manufacturers, a provision that could undermine CME activities or regional or national meetings sponsored by these companies, according to the Massachusetts AFP. Nevertheless, Dimitri said the legislation does not impose a complete ban on activities sponsored by pharmaceutical companies and device manufacturers. "It makes clear what the guidelines are, and we don't have a major problem with that," he said.

The new law also includes the following provisions.