HOUSE DOCKET, NO. 4547 FILED ON: 10/18/2019
HOUSE . . . . . . . . . . . . . . . No. 4134
The Commonwealth of Massachusetts
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OFFICE OF THE GOVERNOR
COMMONWEALTH OF MASSACHUSETTS
STATE HOUSE · BOSTON, MA 02133
(617) 725-4000
CHARLES D. BAKER KARYN POLITO
GOVERNOR LIEUTENANT GOVERNOR
October 18, 2019
To the Honorable Senate and House of Representatives,
For the past 50 years, the US health care system has been focused primarily on
promoting and supporting the technological advancement of medicine. That focus has cured
disease, enhanced therapies, and saved lives. But as that focus, and the success it has achieved,
has dominated what and how we pay for health care, we have failed to appreciate the changing
nature of illness, and the systemic gaps in care delivery that have been created by this approach.
One need look no further than the opioid epidemic to understand what we have missed.
The overprescribing of addictive and potentially deadly pain medication, brought on by a system
in which it is more financially beneficial to write a prescription than it is to provide supportive
and sustained therapy, created an addiction epidemic of gargantuan proportions.
While many people would argue that the fundamental problems with our health care
system are rooted in some provider organizations being paid too much, and others being paid too
little, we would argue the problem is more fundamental than that. Our health care system
rewards those providers that invest in technology and transactional specialty services, at the
expense of those that choose to invest in primary care, geriatrics, addiction services and
behavioral health care.
This is problematic for three reasons. First, the nature of illness is changing. Chronic
illnesses are far more prevalent than they used to be, in part because of the success of modern
medicine in solving many kinds of acute illness over the past five decades. Second, we are an
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aging population. Many of us who live to the age of 60 will make it into our 80s and 90s, where
brain diseases are far more common than they used to be, again in part because of our success in
treating heart disease and many forms of cancer. Third, for a variety of clinical and sociological
reasons, mental health, addiction and behavioral health issues are far more challenging than they
were in the past, and we increasingly recognize how they are intertwined with physical illnesses.
And the primary care shortage that was identified over 30 years ago has gotten worse
over the past three decades.
Simply put, the care delivery and financing system we have today is not designed to take
care of the people and the patients we have become. We pay for a system that is built on
transactions and technological advances, not on collaborative care delivery, therapeutic support,
or a combination of both. While technological advances remain a critical component of
delivering effective health care, a 21st century health system should presume that collaboration
and time are at least as important as technology, and that for many people, physical and mental
health are related. It should reward providers and provider organizations that invest in a
comprehensive set of physical and behavioral health services, and understand that population
based health management requires time and connection.
Solving this problem at the state level is complicated by the overarching role played by
public and private national payors in health care in this country. For the most part, national
payors, including Medicare, use payment policies that favor technology and transactional
medicine at the expense of primary care, mental and behavioral health and addiction services,
and ironically, geriatrics. Almost all providers and payors build their financial models and their
operations using the Medicare fee schedule as their baseline. This makes any decision to deviate
from that model – for example, to offer more mental health services – extremely hard to do.
Federal policy and research funding also drive provider organizations to focus on
specialty services and care, instead of on addiction, mental or behavioral health, primary care or
geriatrics. This makes it financially difficult for any care delivery organization to double down
in the areas where the greatest gaps in the existing care delivery system exist.
The bill I am filing today, “An Act to Improve Health Care by Investing in VALUE,” is
designed to create positive financial incentives for health care providers and payors to rethink
their service delivery and investment decisions. This bill encourages providers and payors to
invest in the behavioral health, addiction and recovery, and primary care and geriatric services
that are underfunded by today’s payment models and incorporate these services more directly
into their care delivery strategies.
The legislation targets those challenges by requiring investments in behavioral and
primary care and establishing a statewide spending target.
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 • Providers and insurers, including MassHealth, will be required to increase
spending on behavioral health and primary care by 30% over three years.
• Calendar year 2019 spending will serve as the baseline, and providers and
insurers will be measured on their performance beginning in calendar year 2023.
• The legislation does not suggest a standard pathway for providers and insurers to
achieve the target.
• Providers and insurers will be required to report their progress on an annual basis
through the Center for Health Information Analysis’ (CHIA) and Health Policy Commission’s
(HPC) existing processes.
• If the target is not achieved, providers and insurers will be referred by CHIA to
the HPC and may be subject to a performance improvement plan which may require them to
identify strategies and opportunities to increase investments in primary care and behavioral
health.
The legislation proposes these increased investments in primary care and behavioral
health while requiring overall spending to stay within the parameters of the state’s overall health
care cost growth benchmark.
This will be a break from the trajectory of the past several decades and may cause some
modest disruptions. But even a cursory review of the literature makes clear that this is the right
direction for our payment systems and our health care providers to move in if we want to create a
payment and care delivery model that properly and cost effectively serves the people of the
Commonwealth.
Our bill also builds upon the foundation put forth by prior health care legislation,
including Chapter 224, the 2012 cost containment legislation. Recent efforts have yielded
moderate success in bending the cost growth curve. However, increasing health care costs
disproportionately fall to individuals and employers, as increases in premiums and cost-sharing
continue to outpace overall expenditures.
This legislation seeks to address excess costs and spending through a multi-faceted
approach that both targets systemic cost drivers and promotes consumer access to high-value,
affordable coverage. The bill strengthens the process by which the Health Policy Commission
(HPC) evaluates, and holds accountable, entities that exceed the cost growth benchmark.
To address year-over-year increases in pharmacy spend, we seek to:
• hold high-cost drug manufacturers accountable through a similar framework used
for payors and providers that exceed the benchmark;
• penalize manufacturers for excessive price increases; and
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 • establish new oversight authority of pharmacy benefit managers (PBMs).
The bill also includes several consumer protections and measures to reduce consumers’
out-of-pocket costs, including prohibitions on surprise billing practices and facility fees, and
reforms promoting access to more affordable, innovative health plans for individuals and
employers, alike.
Further, a stable and affordable insurance market is key to maintaining our near-universal
coverage levels and a well-functioning health care system. To address many of the emerging
federal policy changes and dynamics that may impact the Massachusetts merged market, I will
be issuing an executive order in parallel, to establish an advisory council to conduct an
independent actuarial analysis of the merged market and provide recommendations, including
any regulatory or statutory reforms, for improved market functioning no later than April 30,
2020.
Finally, this legislation promotes access to quality, coordinated care and modernizes
policies to bring Massachusetts in line with other states in areas where we have lagged behind.
These measures include: removing outdated practice restrictions for mid-level clinicians,
creating a new mid-level dental therapist, standardizing urgent care services and advancing
telemedicine through aligned regulatory and coverage policies.
Managing excess costs in the system and promoting increased access to vital services will
support the Commonwealth in recalibrating its health care financing and delivery system towards
a model that values time and positive outcomes, and stands prepared to meet the evolving needs
of our changing patient populations. Many of the reforms we have proposed will also reduce
costs – including to patients and small businesses – while maintaining the quality of care the
people of Massachusetts deserve.
We can’t afford to wait. I look forward to working with the Legislature to enact
comprehensive health care legislation that delivers a more cost-effective, nimble and patient-
centric health care system for the 21st century.
Respectfully submitted,
Charles D. Baker,
Governor
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 HOUSE . . . . . . . . . . . . . . . No. 4134
The Commonwealth of Massachusetts
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In the One Hundred and Ninety-First General Court
(2019-2020)
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An Act to improve health care by investing in VALUE.
Whereas, The deferred operation of this act would tend to defeat its purpose, which is to
improve the delivery of health care and reduce health care costs, therefore it is hereby declared to
be an emergency law, necessary for the immediate preservation of the public convenience.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 6A of the General Laws is hereby amended by inserting after
2 section 16BB the following section:-
3 Section 16CC. (a) There shall be a task force to make recommendations on aligned
4 measures of health care provider quality and health system performance to ensure consistency in
5 the use of quality measures in contracts between payers, including the commonwealth and
6 carriers, and health care providers in the commonwealth, ensure consistency in methods for
7 evaluating providers for tiered network products, reduce administrative burden, improve
8 transparency for consumers, improve health system monitoring and oversight by relevant state
9 agencies and improve quality of care. Through May 2021, the members of the task force shall be
10 the members of the existing Executive Office of Health and Human Services Quality
11 Measurement Taskforce. After May 2021, the task force shall include the following members or
12 their designees: the secretary of health and human services, who shall serve as chair; the
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13 commissioner of public health; the commissioner of mental health; the executive director of the
14 center for health information and analysis; the executive director of the health policy
15 commission; the executive director of the group insurance commission; the assistant secretary for
16 MassHealth; the commissioner of insurance; and at a minimum, 12 members who shall be
17 appointed by the governor, 1 of whom shall be a representative of a provider trade association; 1
18 of whom shall be a representative of a medical society; 1 of whom shall be a behavioral health
19 provider; 1 of whom shall be a long-term supports and services provider; 1 of whom shall be a
20 representative of a community health center serving the Medicaid population; 1 of whom shall be
21 a representative of a Medicaid managed care organization; 1 of whom shall be a representative of
22 a statewide ACO;1 of whom shall be a representative of a commercial managed care
23 organization; 1 of whom shall be a representative for persons with complex health conditions; 1
24 of whom shall be a representative for consumers; 1 of whom shall be a representative of a
25 hospital; at least 1 of whom shall be an academic with expertise in health care quality
26 measurement and 1 of whom shall be a representative of an employer with experience in health
27 care quality measurement. Members appointed to the task force shall have experience with and
28 expertise in health care quality measurement. The task force shall convene annually, with its first
29 meeting occurring not later than January 15, and shall meet not less than monthly or as
30 determined necessary by the chair of the task force. The task force shall submit an annual report
31 with its recommendations, including any changes or updates to aligned measures of health care
32 provider quality and health system performance, to the secretary of health and human services
33 and the joint committee on health care financing not later than January 31 of each year with the
34 first report due in the year following the effective date of this section.
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35 (b) The task force shall make recommendations on aligned measures of health care
36 provider quality and health system performance for use in: (i) contracts between payers,
37 including the commonwealth and carriers, and health care providers, provider organizations and
38 accountable care organizations, which incorporate quality measures into payment terms,
39 including the designation of a set of core measures and a set of non-core measures; (ii) assigning
40 tiers to health care providers in the design of any health plan; (iii) consumer transparency
41 websites and other methods of providing consumer information and (iv) monitoring system-wide
42 performance. The task force shall regularly review its recommended aligned measures of health
43 care provider quality and health system performance, and shall update its recommendations each
44 year.
45 (c) In developing its recommendations, the task force shall consider evidence-based,
46 scientifically acceptable, nationally-endorsed quality measures, including, but not limited to,
47 measures endorsed by the National Committee for Quality Assurance or the National Quality
48 Forum. Such quality measures shall include, but not be limited to, measures used by the
49 commonwealth, the Centers for Medicare and Medicaid Services, the group insurance
50 commission, carriers, and provider organizations in the commonwealth and other states, as well
51 as other valid measures of health care provider performance, outcomes, including patient-
52 reported outcomes and functional status, patient experience, disparities, and population health.
53 The task force shall consider measures applicable to primary care providers, specialists,
54 hospitals, provider organizations, accountable care organizations, oral health providers and other
55 types of providers and measures applicable to different patient populations.
56 (d) No later than March 31 of each year, the secretary of health and human services in
57 consultation with the commissioner of insurance, may establish an aligned measure set to be
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58 used by the commonwealth and carriers in contracts with health care providers that incorporate
59 quality measures into the payment terms pursuant to sections 4 and 4A of chapter 32A, section
60 10K of chapter 118E, section 108N of chapter 175, section 8W of chapter 176A, section 4W of
61 chapter 176B, section 4O of chapter 176G, and for assigning tiers to health care providers in
62 tiered network plans pursuant to section 11 of chapter 176J. The aligned measure set shall
63 designate: (i) core measures that shall be used in contracts between payers, including the
64 commonwealth and carriers, and health care providers, including provider organizations and
65 accountable care organizations, which incorporate quality measures into payment terms; and (ii)
66 non-core measures that may be used in such contracts. In establishing the aligned measure set,
67 the secretary of health and human services may consider factors including but not limited to
68 quality improvement priorities for the Commonwealth, quality measurement innovation, data
69 collection methodology, and measure feasibility.
70 SECTION 2. Section 1 of chapter 6D of the General Laws, as appearing in the 2018
71 Official Edition, is hereby amended by inserting after the definition of “After-hours care” the
72 following 2 definitions:-
73 “Aggregate baseline expenditures”, the sum of all primary care and behavioral health
74 expenditures, as defined by th