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Massachusetts: Comprehensive Approach to Expanding Access

After Massachusetts expanded health care coverage as part of comprehensive health reform in 2006, it faced increased pressures on its primary care system. In response, the state included a set of provisions to improve access to health care services in a cost-containment bill (MA S 2863) passed in 2008 (Table 3). 

     Table 3. Massachusetts' Access Provisions, MA S 2863, passed 2008.

  • Establishes a new Health Care Workforce Center within the Department of Public Health to improve access to health care services in the Commonwealth, with a particular emphasis on primary care. The Center will develop short-term and long-term policies to address workforce shortages.

  • Creates a new loan forgiveness program for doctors and nurses who commit to practicing certain specialties in medically underserved areas, administered by the Health Care Workforce Center.

  • Expands enrollment at the University of Massachusetts Medical School for students committed to primary care specialties.

  • Creates an enhanced "learning contract" for University of Massachusetts Medical students who commit to working four years in primary care in Massachusetts , providing a greater tuition incentive for those who participate but also including a tougher penalty for students who don't complete their commitment.

  • Creates an affordable housing model for health care professionals committed to providing care in underserved regions.

  • Requires health insurers to recognize and reimburse nurse practitioners as primary care providers.

  • In medically underserved areas, expands the number of physician assistants that a physician may supervise from two to four.

  • Establishes a Nursing and Allied Health Workforce Development Trust Fund to increase the nursing workforce and creates a loan forgiveness/incentive program for nursing graduates who commit to serve as nursing faculty for a specified number of years.

  • Directs the MassHealth Payment Policy Advisory Board to study methods of improving reimbursement or bonuses for primary care providers.

 Source: National Conference of State Legislatures, Summary of MA S 2863

These primary care provisions were implemented relatively recently, and it may be too soon to evaluate their impact. They may take years to grow to a scale that will substantially affect the primary care workforce, and current budgetary constraints are likely to slow this process. For example, the Health Care Workforce Center's taskforce on primary care and other issues has had its ability to function limited by budget cuts. "This is a good idea, but so far it has been underfunded," said Dennis Dimitri, M.D., president of the Massachusetts Academy of Family Physicians and vice chair of clinical services in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School.

The state will track how medical students and providers respond to new incentive programs. The planned increase in class size at the University of Massachusetts Medical School, for example, was envisioned as a complement to other incentives to specialize in primary care, with the goal that together they would attract a greater number of students. In another initiative intended to increase the number of physicians from underrepresented ethnic and socioeconomic backgrounds, the University of Massachusetts Medical School is launching a program that would allow high school students to be admitted simultaneously to college and subsequent medical school training.

Massachusetts is also involved in a public–private partnership to repay loans for primary care physicians and nurse practitioners working at community health centers. The partnership is run by the Massachusetts League of Community Health Centers and funded by the state, Bank of America, and a number of health plans and other health care organizations. Between June 2007 and January 2009, the program repaid loans for 57 physicians and 25 nurse practitioners. The state had previously made a variety of investments to increase health center capacity, including grants to help expand health center hours and further promote access.

Dr. Dimitri noted one initiative that is moving ahead quickly: an all-payer, patient-centered medical home pilot run through the executive office of the Massachusetts Department of Health and Human Services. Over the next two to three years, this program will create medical homes in many different types of medical practices, from community health centers to academic health centers to larger group practices with primary care physicians. "The pilot has moved ahead with everyone at the table, including the insurers, the state, physician organizations, primary care providers, and academic medical practice representatives," he said. "Our hope is that it will be very helpful in improving the delivery of primary care, which is critical to attracting providers to the field and expanding access to their services."

For more information, see: Summary of MA S2863, National Conference of State Legislatures, and Primary Care Provider Initiatives, MA League of Community Health Centers,

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