Our Vision
MassHealth has been shifting towards value-based payment models to improve health outcomes and promote health equity while managing health care costs. As part of this effort, MassHealth introduced the Primary Care Sub-Capitation Program in 2023 for providers participating in any of MassHealth’s Accountable Care Organizations (ACOs).
MassHealth now pays participating primary care practices for a set of primary care services through a fixed per-member, per-month payment which is set annually. This model replaces fee-for-service payments for those services. MassHealth designed this program to deliver consistent and reliable monthly revenue to primary care practices and to increase investment to help primary care providers enhance their care delivery. Over time and with the partnership of other payers (e.g., Medicare, commercial insurance), MassHealth aims for this payment reform to increase Massachusetts residents’ access to coordinated and high-quality primary care and improve population health. At the practice level, MassHealth aims to improve both the patient’s quality of care and the experience of the primary care provider. Along with other value-based payment initiatives in Massachusetts, this program is also designed to manage overall health care costs by investing more in primary care.
Program Benefits
Benefits to members
- Flexible, patient-centered care: Members receive primary care that is tailored to meet their needs.
- Expanded access to care: Members have better and more convenient access to primary care through telehealth, same day urgent care, and after-hours or weekend appointments.
- Integrated primary care: Members can access the full range of support they need through their primary care practice team including both their primary care provider (PCP), and other members of the clinical team who can support members in addressing issues ranging from behavioral health to reproductive health, and health-related social needs (e.g., nutrition and housing).
Benefits to providers
- Revenue stability: Primary care practices receive predictable monthly payments based on the size of their MassHealth panel. Payment is not based on visit volume.
- Member engagement: Providers can foster strong, continuous relationships with their MassHealth patient panel so patients get the care they need to stay healthy.
- Flexibility in decision-making: Providers have more flexibility and control in decision-making and can allocate their resources and time in ways that best meet the needs of their patients. This may include expanding their clinical care team to include care managers, behavioral health professionals, community health workers, and other providers who can best support their patient panel.
- Ability to innovate: Through increased investment in primary care, practices receive support to pursue care delivery innovations, such as team-based care, integrated behavioral health, and services to address their patients’ health-related social needs.
Implementation
Nearly 1,000 practices serving over 1 million MassHealth members currently participate in the Primary Care Sub-Capitation Program, representing more than 75% of all primary care practices that accept MassHealth. Since the sub-capitation program started:
- In 2023, over $520 million was paid to practices in sub-capitated payments. Of this, about $100 million was paid to practices for clinical tier enhanced payments.
- By the second year of the program, more than 100 participating practices have expanded or advanced the clinical services provided in their practice (for example, after-hours or weekend sessions, integrated behavioral health services, expanded contraceptive services – see here for the Care Delivery page.
Looking ahead, MassHealth plans to continue investing in primary care, refining its sub-capitation program, and expanding the number of primary care practices participating in the program.