He Released on July 10th The Centers for Medicare & Medicaid Services (CMS) proposed Medicare physician fee schedule for calendar year 2025 sparked debate among healthcare industry professionals. On July 16, the Washington, D.C.-based organization Primary Care Collaboration (PCC) hosted an online discussion with CMS leaders on how Medicare Part B payment policy could improve health by strengthening primary care.
After being introduced by PCC President and CEO Ann Greiner, Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare, said that integrated primary care models have reduced emergency room and hospital visits. This was the conclusion of testing conducted over the past decade by the CMS Innovation Center.
Seshamani went on to explain that CMS is proposing to use these lessons learned to create the new Advanced Primary Care Management (APCM) under the Physician Fee Schedule. “This proposed payment,” Seshamani explained, “uses coding that describes 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, MD, Ph.D., JD, deputy administrator of CMS and director of the CMS Innovation Center, explained that the Innovation Center has partnered with colleagues at the Center for Medicare. Fowler said they have worked closely to develop 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 that many people would fall into this category.” “Level three incorporates not only medical complexity — two or more chronic conditions — but also a level of social complexity, and the way we identify that is Medicare qualified beneficiary status,” Jacobs explained.
This is a multi-year effort aimed at further strengthening the nation’s primary care, said Purva Rawal, Ph.D., chief scientific officer for the CMS Innovation Center. Rawal told the audience that they are soliciting feedback on the design of a future hybrid primary care payment system that incentivizes advanced team-based care. Comments Applications accepted until September 9th.
To avoid reporting burdens, Jacobs explained that the new codes remove some administrative barriers, such as time-based billing requirements. Advanced Care Organizations (ACOs), or advanced primary care models, already meet many requirements; Jacobs stressed that “there are several requirements they no longer need to meet.”
“One of the things that struck us is that this is only available to physicians who are in an advanced model,” said 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 part is measuring quality, according to Navathe. “How can 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 are a lot of different ways to code care management and transition,” said Amy McKenzie, MD, vice president of Clinical Partnership and associate marketing director for Blue Cross Blue Shield of Michigan. “We see disparities in the ability to provide services for smaller, independent practices in rural services,” McKenzie noted. “Either they don’t get provided, or sometimes they provide them and don’t get paid for them.” “What we find successful here in Michigan is providing some of that support mechanism. We have centralized support that helps physicians understand billing requirements,” she said.
The fee-for-service system limits the delivery of personalized and flexible care, said panelist Sarah Coombs, director of health system transformation at the National Partnership for Women and Families, in response to Greiner’s question about how to move toward health equity. Though, she added, the ACPM package is a step forward in the right direction. “A value-based care system by itself is not going to advance health equity.” Additionally, she noted, “Coding and payment for care management requires beneficiaries to share costs, which is a huge barrier for many beneficiaries.”
“We want the care model to drive the payment model, not the payment models to drive the care model,” Navathe said. “CMS is ultimately a payer.” With a collaborative effort, he added, we’re going to achieve the kind of transformation we’re hoping for.
