Lawmakers in Washington are still working on a national model for health care reform. Massachusetts is focused on continuing the successes of health care reform and on the next phase of reform that will bend the curve in the rate of health care spending growth. Left unchecked, health care spending in Massachusetts is projected to nearly double to $123 billion in 2020. By contrast, if we can hold our spending to the rate of growth in the state’s GDP, spending would be $107 billion by 2020. In order to achieve the state’s Health Care Quality and Cost Council (HCQCC) goal of moderating health care spending increases to no more than the rate of growth of the GDP spending needs to decrease by a total 7% between 2010 and 2020.

Earlier this month, researchers from the RAND Corporation, an independent policy research organization, presented a policy brief, Controlling Health Care Spending in Massachusetts, to the HCQCC. The state’s Division of Health Care Finance and Policy commissioned RAND to develop a menu of potential cost containment strategies after consultation with the HCQCC and other Massachusetts stakeholders.

The report, which is unique to Massachusetts, provides analysis of 12 possible interventions that the researchers conclude have the most promise to cut spending in Massachusetts out of more than 75 broad approaches considered. The final recommendations fall into four general categories of policies that could control costs: reforming the payment system; redesigning the health care system to support primary care, prevention, and chronic disease management; reducing waste; and encouraging consumers to make good health choices.

These recommendations will be helpful as we continue to work with a diverse group of stakeholders to develop payment reforms that will promote quality, efficient care in Massachusetts.

Five of the top six approaches in the RAND report deal with the way we pay for health care and are consistent with the recommendation by the state’s Special Commission on the Health Care Payment System to move away from a predominantly fee-for-service system. One promising option is to implement bundled payments, which could decrease spending between 2010 and 2020 by up to 5.9%. In this scenario, providers would receive a single payment for all services related to a treatment or condition (for example for diabetes management or coronary artery bypass graft surgery), instead of each provider receiving a fee for every service delivered. Tied to specific quality measures, this methodology shows promise for moving incentives away from billing for more services toward providing coordinated care with providers held accountable for the outcomes.

Other approaches analyzed by RAND include developing patient centered medical homes and implementing health information technology. They are examples of two approaches that require investment and may not save a lot of money, but the good news is they could be cost neutral. Improving the delivery of primary care is something we must do and implementing health information technology in a comprehensive coordinated fashion is a top priority for the state.

As we work with our partners to find the right solutions for Massachusetts, it is clear that there is no silver bullet for controlling health care costs and spending. RAND estimates the impact of various options individually, but it’s likely that a combination of approaches will be necessary.

In September, the HCQCC will approve a road map to cost containment that will lay out how some of these and other strategies for cost containment could collectively hold down costs and how they could be implemented.

Most of these options would require significant investments of time and dedication on the part of all stakeholders to ensure that efforts bring about the greatest opportunities for savings. Massachusetts achieved near universal coverage by engaging a coalition of stakeholders representing the government, consumers, business and providers. Achieving a cost containment strategy will require the same collaborative effort.

RAND’s thoughtful and comprehensive report will be an important building block as we continue to move forward in partnership with stakeholders in a deliberate and well thought out manner to control costs while maintaining access and quality as priorities.

While it is human nature to focus on what is lost during times of great change, behind the ambitious plan to reconfigure Cambridge Health Alliance is a broad collaborative strategy and story of self-determination that needs to be further explored.

Cambridge Health Alliance plays an important role in our region’s health care system by providing quality services, particularly to low-income residents. It is a safety-net hospital in the truest sense. For months, the Patrick Administration and the hospital have been working together to develop a shared understanding of the essential health care services to the diverse communities Cambridge Health Alliance serves, the limits of our resources, and how we can work together to ensure the hospital system’s future.

The comprehensive reconfiguration recently approved by the CHA Board of Trustees last month reflects a thoughtful, clinically-driven approach to preserving health care access and quality for its patients and communities given the need to respond to today’s financial challenges. It could serve as a national model as other states continue to look to Massachusetts for guidance in crafting health care reform legislation to provide expanded insurance coverage while preserving the principles of caring for those most in need. Some have questioned the need for safety net hospitals in the era of health reform. Yet, it is clear from our collaborative effort that the safety net mission and goals will endure and are still very much needed, especially in mental health services.

We recognize that the proposed changes will not be painless. Cambridge Health Alliance has had to make difficult choices that will impact people’s jobs and lives. Transforming CHA’s health delivery system for sustainability will require consolidation of some inpatient services and six ambulatory centers as well as an eight percent employee reduction. Eventually, we believe our renewed partnership and the resultant plan will be seen as a notable achievement in improving the network’s financial outlook in an era of diminishing resources, while never veering from its vital mission of providing access and services to the poor, elderly, uninsured, and reducing disparities and barriers to health care.

The challenge of maintaining essential services while bolstering CHA’s finances were complicated in the face of the national economic pressures, which further jeopardized public resources and continue to this day. Yet the set of guiding principles that framed the development of our plan never changed. We sought to preserve critical health care services in each of the communities CHA serves, maintain excellence in health care quality and patient access, and continue the academic mission in community medicine, all while seeking opportunities for service delivery efficiency, cost savings and financial stability.

It was a tall order, but we think the plan preserves access to current and growing levels of ambulatory care, emergency room care, and medical-surgical care, albeit in fewer locations through merging services now offered at smaller sites. Creating greater economies of scale where possible was viewed as a much-preferred path to program closures. But the hospital’s innovative and healing mental health services will remain a focus, and, with 95 in-service psychiatric beds, CHA will continue as one of the state’s largest acute hospitals for such care. These services will focus on the communities that are core to CHA’s mission, emphasizing the need for integrated and coordinated care between the hospital and community providers.

Just as important, the plan is based on shared responsibility and an efficient use of all resources, including government dollars to sustain the hospital network’s mission. Soon, we hope to move forward with innovative models, including development of medical home and primary care demonstrations. CHA and hospitals like it with concentrated care to patients dependent on public health coverage will always need support from governments, even as the number of uninsured in the state has declined significantly. The unique services provided by safety-net institutions require special payments from government, and the Patrick Administration is committed to working with the hospital system and the federal government to make this possible.

Dennis D. Keefe
Chief Executive Officer
Cambridge Health Alliance

JudyAnn Bigby, M.D.
Secretary, Massachusetts Executive
Office of Health and Human Services

There are a broad range of opinions about whether the doctor shortage is as described, and how to solve complaints about health care access. The Association of American Medical Colleges has called on medical schools to increase their enrollment by 30%. They have also urged Medicare to lift the cap on Graduate Medical Education funding to support expansion of the workforce. This will be very expensive and may not actually solve the shortage.

More doctors doesn’t necessarily mean better access to care. Adding more dermatologists may decrease the waiting time for botulinum toxin treatments from eight days to six but have no impact on the nearly 30-day wait period to have a changing mole examined. And adding more cardiologists may lead to more angioplasties without decreasing the wait time for consultations for managing individuals with congestive heart failure.

The regional supply of physicians varies widely. We have seen that new physicians tend to settle in areas where supply is already high. This trend is already apparent in Massachusetts: doctors in the state are more likely to practice in Metro Boston than in Western Massachusetts or the Cape, where they are needed most.

What’s more, patient surveys don’t show a correlation between physician supply, patient satisfaction, and access to services. And physicians in regions with a high supply report less coordinated care, lack of continuity, and less communication between doctors.

How is it that having more doctors does not necessarily lead to better access and better care?

The more that payers reimburse per procedure or visit, the more procedures are performed or visits made. As specialists become busier, the number of procedures that are marginal, and perhaps unnecessary, may increase. Typically, the individual consumer is unaware of this phenomenon.

Procedures that had demonstrated value select groups of patients becomes more widely used and become the standard of care for more of the population over time. Many studies demonstrate that this overuse of medical care leads to higher costs without improving quality.

Avoidable hospitalizations are often a sign of poorly coordinated care. These are costly and can lead to harmful complications for patients. We need to decrease unnecessary care, including avoidable hospitalizations, emergency department visits and inappropriate use of technology. Since hospital operating margins depend on hospital beds being occupied we need to change the incentives to promote the most appropriate use of this expensive service.

If we are going to grow the physician workforce to improve health care, we should focus on several principles:

First, we should strive to change the primary care to sub-specialty ratio. Without mechanisms or incentives in place to focus growth in the most critical specialties, simply increasing the workforce will drive students to choose specialties based, in part, on salaries and lifestyle and exacerbate the lack of coordinated care.

Second, medical education should promote the type of care we want doctors to deliver when they graduate. For most trainees (primary care and specialists alike), there must be a more appropriate balance between hospital and non-hospital settings, as well as a focus on preventive care, disease management and patient-centered approaches to care.

Third, we need to reform primary care practice and payment for primary care to promote a focus on coordinating care for patients; delivering preventive care; managing chronic conditions; and delivering acute care in the most appropriate place and by the most appropriate members of the team. And while we are at it, it’s time to abandon fee-for-service payments that drives inappropriate use of care.

Finally, we need better measures of physician supply. Simply assessing wait times for appointments or referrals and/or admission to hospitals doesn’t assess the need for physicians.

The doctor shortage cannot be examined in isolation. At a minimum, we must examine the adoption of technology, the use of non-physician providers, payment policy changes, policies that will promote better and more appropriate use of resources in order to better predict health care workforce needs. In the short-term, interventions like the loan repayment program for primary care physicians have increased the number of primary care physicians and nurse practitioners practicing in community health centers.

As Jim Roosevelt pointed out in a Boston Globe op-ed last week, the key to reforming health care is not only the implementation of universal access to care, but also the improved allocation of resources. We must balance access to care across regions, reduce unnecessary hospitalizations and other services and grow the physician workforce to encourage coordinated care. The long-term sustainability of health care reform depends on it.

Health and Human Services Secretary JudyAnn Bigby, M.D.

There’s more good news. HCFP’s quarterly Key Indicators also reported that care for the state’s remaining uninsured financed by the Health Safety Net – formerly known as the Uncompensated Care Pool – has decreased markedly as insurance enrollment has increased. In the first quarter of the Health Safety Net FY08, there was a 37% decrease in the number of patients using the Health Safety Net in community health centers and hospitals, compared to the same time period last year.

These newest numbers demonstrate that health care reform is working, thanks to diverse efforts to insure people — including the expansion of Medicaid, publicly subsidized insurance and the individual mandate. A diverse group of stakeholders have worked together to make these achievements possible, but we still have work to do to make sure that our progress is sustainable going forward.

Consumers, employers and government must all do their part to get Massachusetts to near-universal coverage. The overwhelming majority of employers in Massachusetts are doing the right thing, with 72% of employers offering health insurance to their employees in 2007.

There is still a small minority of employers who are not covering their employees. When health care reform was first crafted, expected revenue from the Fair Share assessment was significantly underestimated. The state expected to get $41 million in FY07, but the state did not generate any revenue and has collected only $7 million in FY08. Adjusting the regulations will generate approximately $33 million in new revenue to support government-funded health insurance. This is one of a handful of increases in assessments on employers, individuals, providers and health plans made to make sure that everyone makes a fair contribution to the costs of health care reform.

The new Census numbers reaffirm what we have been seeing in Massachusetts as we continue to implement health care reform. According to the Census, Massachusetts now has the lowest rate of uninsurance in the country, with a two-year average of 7.8% in 2006-2007. That’s down 2.4% from the 2005-2006 period.

The extraordinary decrease in Massachusetts’ rate of uninsurance is the product of a multi-pronged approach that has included the expansion of Medicaid and subsidized programs, the individual mandate, the Fair Share assessment, and diverse outreach initiatives. The Census report reaffirms that the time, energy and resources we are putting into making health care reform a success are paying off.

We can also see what kind of an impact Massachusetts’ health care reform efforts are having on the national level. From 2006 to 2007, the number of uninsured in the United States dropped by 1.34 million people. In Massachusetts, the number of uninsured dropped by 317,000 over the same period. Crunching the numbers, we see that Massachusetts is responsible for 24% of the overall national decline, while we account for only 2.1% of the population. This is amazing and speaks to the impact that individual state actions can have on the national level. Presidential candidates, are you listening?

JudyAnn Bigby, M.D.
Secretary for Health and Human Services

Extending the state and federal partnership embodied in Massachusetts’ Medicaid waiver is critical to our historic effort to reach near universal health insurance coverage.

Why should the federal government support our waiver renewal?

Evidence of the successes of health care reform continues to come in. The 1115 Medicaid Demonstration Waiver has helped us dramatically reduce the number of working-age adults in Massachusetts who are uninsured. Not only are more people insured, but we have seen an expansion in access to health care. Primary and preventive care are on the rise as we continue to implement health care reform. More low-income adults report having a primary care provider and fewer have unmet health care needs.

The Medicaid Waiver is a large part of the success. Compared to January 2006 approximately 55,000 more individuals have been enrolled in MassHealth programs. With the current waiver we are able to cover more low-income adults who are chronically unemployed in the MassHealth Essential program. Some low-income individuals who are not able to afford employer sponsored health insurance qualify for premium assistance through the MassHealth program. The waiver is also instrumental in helping to fund affordable coverage for other low-income individuals who qualify for the CommonwealthCare program. Covering these populations is key to the Commonwealth’s goal to reach near universal coverage.

The Medicaid waiver has been instrumental in transforming coverage for low-income individuals in Massachusetts. As coverage for individuals has increased, the number of individuals who have been dependent on the so-called “free care pool” has declined. The total number of hospital inpatient discharges and outpatient visits billed to the pool declined by approximately 11% overall from Pool Fiscal Year 2006 to Pool Fiscal Year 2007. Community health center Pool visit volume decreased by 25% during the same period. The decline in the number of individuals who depend on the “free care pool” represents the success of the Commonwealth in increasing the number of uninsured. With insurance, those who have previously depended on the pool for emergency care, have access to primary and preventive care.

With this success have come challenges. Our tremendous success in enrolling people in Commonwealth Care and MassHealth and the continued demand for these programs requires on-going commitment from both the state and the federal government. I am proud that the Patrick Administration, our legislative leaders and all of our health reform stakeholders are steadfast in their commitment to reach near universal coverage and are actively engaged in doing their part to make that happen. The Commonwealth has made a commitment to this demonstration project by investing state resources. We need the federal government to continue their commitment with us as well. We rely on federal funding for roughly half of all state spending for subsidized insurance. In our meetings Secretary Leavitt and other Bush administration officials again voiced their support for the Massachusetts model, as they have in the past. They were clearly pleased with the results we have been seeing in Massachusetts, particularly in our ability to maintain private insurance rates and prevent “crowd out.”

The Commonwealth has made a commitment to continue this successful demonstration and to address the cost and quality of the care we deliver and support through our Medicaid program. I am hopeful that we will be able to announce shortly that we have an agreement that will allow health reform to continue to be the success that it has been with federal support.

Health and Human Services Secretary JudyAnn Bigby, M.D.

These recommendations reflect the overarching goals set by the Council last year. We are committed to reducing the annual rise of health care costs to no more than the unadjusted growth in Gross Domestic Product by 2012; ensuring patient safety and effectiveness of care; eliminating racial disparities in health and health care; and improving screening for and management of chronic illnesses.

The Council’s Annual Report makes specific recommendations for action in these and other key areas. For example, in an effort to improve care and management of chronic diseases like congestive heart failure, diabetes and asthma, the Council recommends that the Commonwealth develop a blueprint for a statewide model system of care that improves the health status of people with or at risk for chronic conditions. Unnecessary hospitalizations related to chronic conditions are a major source of inefficiency and represents a major opportunity for decreasing health care costs. Preventable hospitalizations have been increasing in Massachusetts; the highest rates of preventable hospitalizations are among black Massachusetts residents with 21.3 preventable
hospitalizations per 1,000 compared to 18.2 among whites. The Division of Health Care Finance and Policy estimates that up to 15% of hospital admissions are due ambulatory sensitive conditions that could be prevented through the timely and effective use of primary care. Clearly, preventing unnecessary hospitalizations is beneficial to patient’s health, quality of life, and productivity. But in addition preventing even a fraction of these hospitalizations would result in considerable savings for the Commonwealth. In 2005, the cost of hospitalizations in Massachusetts was $60 million for diabetes and related complications; $30 million for asthma; and $100 million for congestive heart failure cost.

The Council recommendations call for convening a working group of a broad range of stakeholders to design a plan that focuses on patient self management; physician practice coordination and support; transitions from one patient care site to another; community resources; health information systems; and payment system alignment. We are fortunate that many leaders in Massachusetts are committed to joining together to address chronic diseases. Massachusetts was recently informed that we are one of nine states chosen to participate in a State Quality Institute sponsored by the Commonwealth Fund and Academy Health. Our partners in this initiative include the legislature, ably represented by Senator Richard Moore and Representative Patricia Walrath, and the Massachusetts Hospital Association and Tufts Health Plan representing private providers in the state. Through this effort the state will have access to experts who have developed meaningful transformation of the chronic care system in other states.

Earlier this month the Dartmouth Atlas Project released a report that demonstrates ongoing variation in the practice of medicine and in the use of medical resources. This finding is particularly prevalent at the end of life. The report provides data that suggests that more utilization of health care does not correspond with increased quality of life or better outcomes and, in fact, can be harmful. The Council includes very thoughtful recommendations about improving the quality of care by enhancing processes of care that would guarantee that individuals get the care they want. The Council recommends that hospitals, nursing homes, physicians and other providers should implement, by 2010, a process for communicating patients’ wishes for care at the end of life, similar to the Physician Order for Life Sustaining Treatment (POLST) processes currently in use in Oregon, Washington, New York, West Virginia, and other states. This is an important initiative that will have implications for many individuals in Massachusetts since there is widespread evidence that many patients and families are not aware of their options for care at the end of life. Even those patients and families who clearly communicate their wishes may not have their wishes honored.

These are just two of the recommendations made in the HCQCC Annual Report. To download a copy of the full report, visit the Council’s website. The Council’s diverse strategies complement and build on other state efforts to improve health care quality and contain costs underway through the HealthyMass initiative and at the Department of Public Health, the Office of Medicaid and elsewhere.

Achieving the goals the Council has set will require multiple changes in the system, including increasing resources on prevention and wellness, reforming the payment system to better align payment with quality of care, and other large system changes.

Health and Human Services Secretary JudyAnn Bigby, M.D.

Health care reform will not succeed with insurance reforms alone, and investing in health care reform and primary care are key priorities for the Patrick Administration. We must promote policies that ensure that people have the right care in the right place. Massachusetts must receive the best value from health care expenditures, while ensuring health care is safe, timely, efficient, effective, equitable and patient-centered.

We continue to support the goal of near-universal coverage, and the first year of this innovative program has been a success. More than 300,000 people who were uninsured now have health coverage. Yet even beyond continuing to support expanded coverage through Commonwealth Care and MassHealth, there is other important work to do. We need to focus more attention on health care costs and improved access to primary care services for all people in Massachusetts. Several initiatives in the Governor’s budget reflect these goals.

For example, we propose expanding pay-for-performance programs in MassHealth by extending performance based reimbursement to MCOs, nursing homes and primary care physicians. Implemented in a way that rewards health outcomes, pay-for-performance represents a shift away from a straight fee-for-service model that does not recognize the quality of care provided.

Expansion of chronic care management, focusing on the small percentage of patients who account for the majority of costs in the health care system, can improve care while decreasing costs through preventing avoidable hospital admissions, readmissions, and unnecessary emergency department visits. The Governor’s budget supports this, especially for MassHealth Primary Care Clinician Plan members. We are committed to supporting primary care physicians’ efforts to provide the type of care they want to provide for their patients in their practices by supporting a team approach to care management. As we move forward with the HealthyMass initiative, we plan to coordinate models to support a medical home across public payers.

Access to primary care is also a growing concern in the Commonwealth. Our budget includes $1.7 million to continue to support the Primary Care Workforce Development and Loan Forgiveness Grant program. This program enhances the recruitment and retention of primary care physicians at community health centers. In FY09, the Governor proposes to expand eligibility for this initiative to include primary care physicians recruited by community hospitals.

These are some of the many exciting and important health care reform initiatives supported in the Governor’s budget. We make recommendations that will maintain the expanded coverage enacted by Chapter 58, while also focusing on other areas that require improvement. These reforms are necessary to ensure the health of the Commonwealth.

JudyAnn Bigby, M.D.
Secretary for Health and Human Services

By aligning policies and practices, these agencies will work together to ensure access to care; contain health care costs; advance health care quality; promote individual wellness; and develop healthy communities. Collaboration is the key to success, and working together with those in state government—as well as other key stakeholders—will be essential. Early on in our work, we will decrease administrative burdens on providers; adopt strategies to improve quality of care; focus on decreasing the impacts of chronic disease; and align payments to support primary care and community hospitals.

Pay for performance initiatives are increasingly recognized as a strategy for improving health care quality, and many payers have adopted this strategy. Providers are clamoring for coordination of performance measures across payers, so that they do not waste time and resources capturing and measuring unique outcomes for every payer. Collectively, the GIC, Commonwealth Connector and MassHealth cover more than 1.6 million people in the Commonwealth and contract with many of the same providers. One of our initial HealthyMass strategies will coordinate and align performance measures and incentives across these state agencies. Aligning our policies will amplify the impact on quality of care and simplify the processes for providers who must meet the performance standards.

We will also improve efficiencies and reduce the burden on and expense to providers by consolidating the processes through which they submit common data to different state agencies. By streamlining administrative functions, the state will also gain greater flexibility and efficiency in accessing and using the data.

According to an October report from the Milken Institute, Massachusetts ranks 40th in the nation in its burden of chronic disease, which negatively impacts the state’s economy because of associated health care costs and the health of our workforce. Through the HealthyMass initiative, state agencies will work together and with partners in the private and nonprofit sectors to develop a coordinated approach to prevention and management of chronic diseases – starting with obesity and diabetes. This effort will focus on individual and community wellness and prevention; the elimination of gaps in early diagnosis of diabetes; coordinated disease management that will reduce the incidence of diabetes across the state (especially within racial and ethnic minority communities); and decrease unnecessary hospitalizations and emergency department visits.

We will also develop alternative payment strategies that prioritize the delivery of high quality, efficient and effective health care, and hold providers accountable for specific outcomes. Reform of the current payment system will allow for better care—rather than just more care—and care in the right place.

The HealthyMass initiative represents a genuine transformation in how we approach health and health care in Massachusetts. Our cross-agency efforts will work towards a more comprehensive approach to health that recognizes the inextricable links between cost, quality, access and prevention and wellness. Our motto is “Our Health is Our Commonwealth.”

JudyAnn Bigby
Secretary for Health and Human Services

As more and more individuals acquire insurance, we must recognize that insurance does not ensure access. Having a regular provider and a regular place to go for health care is necessary to ensure that people get the right care in the right place.

The demand for primary care providers in Massachusetts is on a lot of people’s minds. Anecdotally, people relate that primary care providers are a scarcity, that wait times to see a provider are often unacceptably long and that too many providers are not taking new patients.

Despite one of the highest physician to population ratios in the country, a smaller percentage of physicians in Massachusetts practice primary care. There are simply not enough providers to meet Massachusetts’ evolving health care needs, given the increasing enrollment in managed care plans. Who would ever guess that a small state with four medical schools and two dental schools could have Health Professional Shortage Areas (HPSAs)? But we do – 23 Primary Care HPSAs; 16 Dental HPSAs; and six (6) Mental Health HPSAs.

There are many reasons for the shortage of primary care providers. Fewer medical school graduates are choosing primary care as a career, a national trend that has increased in the last decade. Primary care physicians have among the lowest salaries of all physicians but have just as much medical debt as other specialists. The relatively low salaries and the cost of living in Massachusetts present significant challenges for new primary care practitioners.

Although Massachusetts is rich in health care professionals—given our nationally recognized medical and dental schools, as well as schools for nursing and other mid-level training programs—there is uneven distribution of primary care and other providers. As a result, health and access disparities across racial, ethnic, geographic (including rural areas) and economic groups are prevalent. Barring a change in the current trend, these shortages can only be expected to increase over time. We are committed to working with all stakeholders to develop an effective strategy for recruiting and retaining PCPs.

First, we must do a better job of understanding the extent of the shortage in Massachusetts. We know how many physicians we have per capita—again significantly higher than the national average. What these data do not tell us is where these physicians practice; whether they practice full-time or part-time; if they plan to retire soon; or whether they spend more time as researchers than as providers of patient care. The Department of Public Health and Commonwealth Medicine are discussing a strategy to develop a Massachusetts-based determination for shortage areas and to identify guidelines for targeting state resources and dollars that are not constrained by federal guidelines.

Second, we must expand our base of primary care providers through programs like the Bank of America-funded initiative developed by Partners HealthCare with the Massachusetts League of Community Health Centers, which provides loan repayment for primary care physicians who practice in community health centers. The state added money to this program to ensure that all health centers across the state can participate. We must also explore how this program can benefit other communities served by community hospitals and how other providers, such as nurse practitioners and dentists, can benefit from the program.

Third, we must demonstrate that we value primary care providers by recognizing their complex and very important role as providers of preventive services and primary care, managers of chronic disease, and leaders of teams of health care providers caring for people around the clock and in a variety of health care settings. Primary care physicians deserved to be paid for all the care they deliver. We must make it possible for primary care providers to take time to develop relationships with their patients and address the wide range of social and medical issues their patients present.

The state is reviewing ways that we can streamline administrative practices, such as prior approval, so that physicians and other members of the primary care team can spend more time on direct care. Reimbursement must recognize the value of the medical “home” in promoting prevention and wellness, managing chronic illnesses, and in decreasing disparities in health care with the primary care physician as the team leader responsible for this care.

Fourth, we must acknowledge that medicine has evolved over the last several decades. There are new opportunities for delivering some aspects of primary care that emphasize the role of nurse practitioners and others and that promote care for acute problems in settings that are convenient and accessible to individuals, while still coordinating that care with their primary care provider.

Being a primary care physician is a privilege and provides a unique opportunity to make a difference—I know from first-hand experience. It is unfortunate that there are so many forces leading smart and talented people away from a field of medicine that is so rewarding. We have made many advances in medicine and understand the potential that delivering primary care has in improving the lives of individuals and their families. We must make sure that everyone has the opportunity to benefit from having a good primary care doctor.

JudyAnn Bigby, Secretary for Health and Human Services

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