UMass Chan Medical School has worked with the Massachusetts Executive Office of Health and Human Services (EOHHS) since 2014 to develop risk models for MassHealth to account for how social determinants of health (SDH) and medical complexity jointly predict total health care cost.i The Primary Care Activity Level (PCAL) framework was originally developed by Ash and Ellis in 2012 to calculate risk-adjusted bundled payments for comprehensive primary care in a commercially insured population.ii It was designed to recognize patient differences in the expected cost of all services that primary care practitioners (PCPs) should be providing. Payments based on PCAL are higher for medically and/or socially complex patients than for less complex ones.

In 2023 MassHealth is implementing a Primary Care Capitation program for Accountable Care Organization (ACO) primary care (PC) practices, which extends value-based payment to the provider level. Complex patients need more PC services to manage their needs than less complex patients do, yet such differences in patient complexity are not adequately reflected in fee-for-service reimbursements for primary care procedures. Here we present the development of a PCAL model that can be used to adjust primary care capitation payments based on the health status of each member; the model has been fit to MassHealth-specific data and in consideration of the state’s policy goals.