The following article was published by our friends at Wellpoint.
December 2, 2024
The rising cost of healthcare services in Massachusetts continues to be a challenge for many families with employer-sponsored or individual health insurance. According to a recent report by the Massachusetts Health Policy Commission (HPC), Massachusetts has the second-highest family health insurance premiums in the country. The same report highlighted that two in five Bay Staters are putting off seeing a doctor or going to a hospital because of the high cost of healthcare.
State policy think tanks have found that hospital prices and prescription drug prices are the two main drivers of healthcare costs. It’s no secret that our state has struggled to mitigate healthcare cost growth over the last decade due to escalating hospital and provider prices. In fact, total healthcare expenditures per capita in Massachusetts rose almost 6 percent – over twice the rate of inflation – in 2022, per the Center for Health Information and Analysis (CHIA). The bottom line: healthcare costs are growing faster than household income, and that’s a huge problem for all of us.
The case for primary care
Enhancing access to primary care can improve whole health and lower the annual rate of growth in healthcare costs. According to the Purchaser Business Group on Health, “adults who regularly see a primary care physician have 33 percent lower healthcare costs and 19 percent lower odds of dying prematurely than those who see only a specialist”. However, spending on primary care represented only 6.7 percent of total medical spending for commercially insured members, according to data from CHIA. That’s why we need to transform the existing healthcare system from a model that rewards “sick care” toward a model that prioritizes primary care, whole health, and affordability for consumers, employers, and taxpayers.
Whole health is not only about your physical health, but the behavioral, emotional, and social factors that affect your overall well-being. Non-clinical factors like access to nutritious food and other social supports can determine up to 80 percent of health outcomes. Primary care physicians (PCPs) are well positioned to help their patients better understand and manage such drivers of health – think of them as the quarterbacks of healthcare.
PCPs are equipped to empower us in our health journey, manage chronic conditions, and coordinate care to ensure tests aren’t needlessly repeated and that we are on track with our health habits. They can also screen for mental health conditions like anxiety and depression and provide treatment or refer patients to therapists or other services. Moreover, regular engagement with a PCP drives more immunizations, education around the importance of healthy habits like diet and exercise, and counseling about alcohol and drug use as well as smoking cessation.
In fact, studies have shown that people who have a relationship with a trusted PCP are more likely to have higher satisfaction with the healthcare system and are less likely to need care at an emergency room or through a hospital admission, which can lead to higher costs. But alarmingly, studies show declining access to primary care in recent years. We must work together to shift resources from “sick care” to primary care, community health centers, digital tools, and home-based services that empower people to live healthier lives while lowering the total cost of care. A simple step we can all take is to have an annual wellness exam with a PCP each year. Your health plan can help you find one covered by your plan.
Advancing value-based payment models
One way to enhance primary care is to implement reimbursement models that prioritize primary care and incent PCPs to keep people healthy. At Wellpoint, we are working to accelerate growth in value-based payment models that reward primary care providers for care coordination, better health outcomes, and care experience rather than on the volume of services provided under the traditional fee-for-service system. Our goal is to align clinical and financial incentives so that primary care providers are empowered to provide better care at lower costs.
While primary care is not a panacea, it is an underutilized resource that requires prioritization, education, investment, and meaningful incentives if we are serious about lowering healthcare costs. The more we work together to expand access to primary care and unlock market forces that empower consumers to take better control of their health, the closer we can get to making healthcare affordable in Massachusetts.
David Morales is the general manager of Wellpoint, a health benefits company serving state and municipal employees, retirees, and their families insured through the Commonwealth of Massachusetts Group Insurance Commission. Learn more at wellpointmass.com.