CMS and Healthcare Executives Discuss Advanced Primary Care Models Under Physician Fee Schedule

The release on July 10 of the proposed Calendar Year 2025 Medicare Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS) has prompted discussions among healthcare industry professionals. On July 16, the Washington, D.C.-based Primary Care Collaborative (PCC) hosted an online discussion with CMS leaders about how Medicare Part B payment policy could improve health through strengthening primary care.

After being introduced by PCC President and CEO Ann Greiner, Meena Seshamani, M.D., deputy administrator with CMS and director of the Center for Medicare, remarked that comprehensive primary care models have reduced emergency and hospital visits. This was concluded by tests conducted over the last decade by the CMS Innovation Center.

Seshamani went on to explain that CMS is proposing to use these lessons learned in creating the new Advanced Primary Care Management (APCM) under the Physician Fee Schedule. “This proposed payment,” Seshamani explained, “uses coding describing certain primary care services that would be provided by Advanced Primary Care teams with adjustments for patients' medical and social complexity to promote health equity.” Additionally, she added, “These services would also be tied to primary care quality measures to improve health outcomes for people with Medicare.”

Liz Fowler, M.D., Ph.D., J.D., deputy administrator with CMS and director of the CMS Innovation Center, explained that the Innovation Center has partnered with colleagues in the Center for Medicare. Fowler said they have worked closely together to craft the request for information on potential payment policies to support advanced primary care.

Doug Jacobs, M.D., Ph.D., CTO of the Center for Medicare, detailed the three levels of APCM codes based on patient complexity. “Level one is for patients with one or fewer chronic conditions,” he explained. “Level two is for patients with two or more chronic conditions,” Jacobs continued. “In Medicare in particular, we anticipate a lot of individuals would fall into this bucket.” “Level three incorporates not just the medical complexity, two or more chronic conditions, but also a level of social complexity, and the way that we're identifying that is the qualified Medicare beneficiary status,” Jacobs explained.

It's a multi-year effort intended to further strengthen the nation’s primary care, noted Purva Rawal, Ph.D., CSO of the CMS Innovation Center. Rawal told the audience they are requesting feedback on designing a future hybrid primary care payment system that incentivizes advanced team-based care. Comments are accepted through September 9.

To prevent reporting burden, Jacobs explained that the new codes eliminate some administrative barriers, such as time-based billing requirements. Advanced Care Organizations (ACOs), or advanced primary care models, already fulfill many requirements; Jacobs underscored, “There are several requirements that they no longer need to meet.”

“One of the things that was highlighted for us is that this is only available to clinicians who are in an advanced model,” remarked panelist Amol Navathe, M.D., Ph.D., vice chair of MedPAC, and associate director of the Center for Health Incentives and Behavioral Economics in the Department of Medical Ethics at the University of Pennsylvania. The most challenging piece is the quality measurement according to Navathe. “How do we do that without really stimulating a ton of administrative burden?” he asked.

“One of the things we see with our primary care physicians is that there just are so many different ways to code for care management and transition,” said Amy McKenzie, M.D., vice president of clinical partnership and associate CMO of Blue Cross Blue Shield of Michigan. We see disparities in the ability to deliver services for smaller independent practices in rural services, McKenzie noted. “Either they don’t get delivered, or sometimes they’re delivering them and not getting paid for them.” “What we found here successful in Michigan is providing some of that support mechanism. “We have some centralized support that helps physicians understand the billing requirements,” she mentioned.

The fee-for-service system limits the delivery of flexible, personalized care, said panelist Sarah Coombs, director for health system transformation at the National Partnership for Women and Families, in response to Greiner’s question on how to move towards health equity. Although, she added, the ACPM bundle is a step forward in the right direction. “A value-based care system in and of itself is not going to advance health equity.” Additionally, she remarked, “Care management coding and payment does require beneficiary cost sharing, which is a large barrier for many beneficiaries.”

“We want the care model to drive the payment model, not the payment models to drive the care model,” Navathe remarked. “CMS is ultimately a payer.” With collaborative effort, he added, we are going to get the type of transformation that we hope for.