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Response to the Centers for Medicare & Medicaid Services CY 2025 Advanced Primary Care Hybrid Payment Request for Information

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on policy changes for Medicare payments under the physician fee schedule, and other Medicare Part B issues, effective on or after January 1, 2025.¹ The announcement included a description of the proposed advanced primary care management (APCM) services and a request for information (RFI) regarding the proposed changes to CMS’ advanced primary care hybrid payment (CMS, 2024b). This report will respond to select questions from both the APCM section of the proposed rule (starting on p. 249) and the RFI (starting on p. 315). The RFI states (CMS, 2024b):

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¹ The full text of the proposed rule is available at https://public-inspection.federalregister.gov/2024-14828.pdf. The APCM description begins on p. 249 and the RFI begins on p. 315 (accessed September 5, 2024)

The National Academies of Sciences, Engineering, and Medicine (the National Academies) appointed the Committee on the Response to the Centers for Medicare & Medicaid Services CY 2025 Advanced Primary Care Hybrid Payment Request for Information to prepare this consensus report.² The committee’s statement of task, which includes select questions from the APCM section and the RFI, is in Appendix A. Brief biographical sketches of committee members and staff are in Appendix B. RFI text and questions that the committee is addressing in this report are denoted below in boxes.

ADVANCED PRIMARY CARE MANAGEMENT SERVICES

As part of the CY 2025 proposed Medicare physician fee schedule rule (CMS, 2024c), CMS will adopt coding and payment policies for the provision of APCM services. The committee summarizes these policies in this section. As proposed, APCM operationalizes many of the recommendations from the 2021 National Academies report, Implementing High-Quality Care: Rebuilding the Foundation of Health Care. CMS states that it will use the National Academies definition of high-quality primary care as its

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² The committee members make up a subgroup of the National Academies Standing Committee on Primary Care, which was appointed in August 2023 to advise the federal government on primary care policy.

definition for advanced primary care.³ In addition to building on the National Academies recommendations, the APCM services incorporate elements of several specific, current Medicare care management programs including non-complex and complex chronic care management, principal care management, and communication technology-based services (CMS, 2024a).

Under the proposed rule, starting on January 1, 2025, clinicians (physicians and other advanced practice providers) who are the focal point for all needed health care services and are responsible for all of the primary care services for a person will be able to use the new APCM Healthcare Common Procedure Coding System codes.⁴ Codes may be reported once per month by one single clinician. Level 1 APCM services are for patients with one or fewer chronic conditions and are valued at 0.17 relative value units (RVUs).⁵ Level 2 APCM services are for patients with two or more chronic conditions and are valued at 0.77 RVUs. Level 3 APCM services are for qualified Medicare beneficiaries with two or more chronic conditions and are valued at 1.67 RVUs.

The APCM service elements and practice capabilities include the following 10 items:

1. Consent
2. Initiating visits for new patients
3. 24/7 access to care and care continuity
4. Comprehensive care management
5. Patient-centered comprehensive care plan
6. Management of care transitions
7. Practitioner, home-based, and community-based care coordination
8. Enhanced communication opportunities
9. Patient population–level management
10. Performance measurement

The proposed rule states that documentation of consent in the patient’s record is required to bill APCM codes. Additionally, a clinician who is

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³ Implementing High-Quality Care: Rebuilding the Foundation of Health Care defines high-quality primary care as “whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities” (NASEM, 2021).

⁴ This coding system is a collection of standardized codes that represent medical procedures, supplies, products, and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers. See https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system (accessed August 14, 2024).

⁵ RVUs are a measure of relative value that consider time, intensity, and cost to calculate payment for physician-delivered services.

part of a Medicare Shared Savings Program accountable care organization (ACO) (CMS, 2024e), a CMS Innovation Center ACO, the Making Care Primary demonstration, or the Primary Care First demonstration (CMS, 2024b) will satisfy the proposed practice-level requirements for patient population-level management and performance measurement. Clinicians who are eligible for the Merit-based Incentive Payment System (MIPS) who register for and report the Value in Primary Care MIPS Value Pathways will satisfy the performance measurement requirement (CMS, 2024f). Use of certified electronic health record technology is also required to participate, as care teams must support 24/7 access to care, continuity of care, and management of care transitions. Specifics of demonstrating ability to deliver other service elements are yet to be defined.

CMS outlines several guiding principles that it used to design the payment structure and policies for APCM services, including the following:

• CMS should provide stable payments to support advanced primary care.
• APCM codes are intended to be used in conjunction with existing evaluation and management (E/M) codes.
• Patients will self-select who provides the services through the consent process.
• APCM codes will not be time based or include time frame restrictions.
• Not all APCM elements must be delivered in a given month, but they should be tailored and person centered.
• APCM services will often be provided by an interprofessional team under the supervision of the billing clinician.
• Clinicians in an advanced primary care practice will be able to bill APCM services for nearly all patients for whom they assume primary care responsibility.
• Beneficiaries with social risk factors necessitate greater resource requirements.
• Billing and documentation requirements will be simplified compared to existing chronic care management, principal care management, and communication technology–based services codes.
• There will be a low-burden method for clinicians to meet APCM billing requirements by using other ways that clinicians fulfill performance requirements; for example, current reporting required for participating in a Medicare Shared Saving Program ACO will also satisfy some APCM reporting requirements.
• Other care management services (e.g., behavioral health integration, addressing health-related social needs, remote physiologic monitoring) complement APCM services and can be billed separately.

CMS is seeking feedback on several aspects of APCM services in its proposed rule. In this section, the committee is offering responses to the following APCM-related questions.

• Does the proposed APCM payment policy reflect CMS’ efforts to recognize the delivery of advanced primary care?
• Do the proposed elements and requirements appropriately reflect the care management services for advanced primary care, and are the service descriptions accurate?
• Is the qualified Medicare beneficiary status an appropriate indicator to identify beneficiaries with added social risk, and what is an equivalent marker of social deprivation for use in commercial markets?
• What is a low-burden method for practitioners to meet APCM billing requirements?
• What is the best approach to effectively educate both practitioners and beneficiaries on the benefits of APCM, especially as it reflects a new bundle of services that may have previously been separately billed?

Committee Response

Advanced Primary Care Delivery

• The committee supports the proposed APCM services as they are highly aligned with and operationalize many of the recommendations from Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021). For example, APCM has the potential to (1) transition primary care payment to greater hybrid payment, (2) increase total payment to primary care, and (3) improve the quality of primary care delivered in the United States.
• The 10 APCM service elements described in the proposed rule accurately reflect the elements of high-quality primary care detailed in Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021).
• The proposed APCM payments and policies effectively recognize the delivery of advanced primary care. Continuing both APCM and E/M payments should increase total payment to many primary care practices, which is needed to support the infrastructure and resources to deliver APCM services.
  • The described care management services build on findings and lessons learned from multiple CMS Innovation Center

• demonstration programs (Finke et al., 2022; Mathematica, 2018).

• Recommendation 1: The Centers for Medicare & Medicaid Services should use advanced primary care management (APCM) payments and policies as a tool to expand the primary care workforce, increase access to advanced primary care for Medicare beneficiaries, and transform more primary care practices to advanced primary care practices.
  • As proposed, APCM appears to increase payment to advanced primary care practices by covering services that are not currently reimbursed while allowing practices to continue E/M codes for visits. APCM payments should represent an increase in overall payment to advanced primary care practices.
  • Primary care currently does not have the capacity to care for all people in the United States due in part to the primary care workforce shortage (Jabbarpour et al., 2024). The number of primary care physicians treating Medicare beneficiaries per 1,000 beneficiaries has declined (MedPAC, 2019), and many primary care clinicians limit the number of Medicare beneficiaries that they will see, as Medicare often reimburses less than commercial insurance and people with Medicare are more likely to have more chronic conditions and complex needs (Brooks et al., 2021). Additionally, family physicians in 2022 cared for 25 percent fewer patients than family physicians did a decade earlier. The scope and complexity of primary care services has expanded, so patients often require more frequent and longer office visits (Bazemore et al., 2024). Increased payment through APCM should encourage more primary care clinicians to care for more Medicare beneficiaries.
  • APCM payments will provide a mechanism for practices not able to participate in the Making Care Primary or the All-Payer Health Equity Approaches and Development Model programs to participate in a hybrid payment program.

Qualified Medicare Beneficiary Status

• Using the qualified Medicare beneficiary status, a marker for greater social needs, is a good first approach for CMS and advanced primary care practices to stratify the risk of Medicare beneficiaries to whom they provide APCM services (CMS, 2024d). Future risk stratification should identify other people in need of more intensive APCM services, such as those with disabilities, those with serious mental and other chronic illnesses, or those with disproportionate

• use of potentially preventable acute care services such as emergency department visits and hospitalizations. Risk stratification is discussed in greater detail in the committee response to the “Health Equity and Clinical and Social Risk” section below.

Managing the Burden on Participating Practices

• While Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care concluded that primary care improves the health and equity of communities and is a common good worthy of public investment, many primary care practices in the United States are not practicing advanced primary care (NASEM, 2021). Infrastructure and support are needed to help primary care better deliver access and first contact, continuity, comprehensiveness, coordination of care, and proactive population health. APCM payments should give more primary care practices resources and support to provide advanced primary care (Darvesh and McGill, 2022; Haggerty et al., 2003; Vimalananda et al., 2018).
• Recommendation 2: The Centers for Medicare & Medicaid Services (CMS) should ensure that the implementation of the APCM payment and policies adhere to the guiding principles included in its proposed rule. To support primary care practices participating in the APCM program, CMS should minimize the burden for practices to demonstrate the delivery of APCM services, limit duplication with current reporting mechanisms, provide sufficient payment and resources to support the full interprofessional primary care team, and ensure that payments flow through to support the team delivering the APCM services.
• As described in the proposed rule, APCM services should be individualized, and it would not be appropriate to require that services be delivered at specified intervals. Using existing program reporting requirements to satisfy APCM eligibility criteria minimizes unnecessary reporting burden across programs.
  • CMS has only defined three mechanisms to demonstrate delivery of APCM services and only linked these processes to satisfying some of the 10 APCM requirements. If fully implemented effectively, these three mechanisms may be sufficient to demonstrate delivery of all APCM services. For practices participating in CMS Innovation Center ACOs, Shared Savings Program ACOs, Making Care Primary, and Primary Care First, the addition of obtaining and documenting consent alone may be considered sufficient to demonstrate capacity for APCM services.

• The consent process could require a full description of APCM services that the patient will receive and a description of the clinician and interprofessional team that will deliver the APCM services. This could help to ensure that patients know the scope of services they are entitled to receive and clarify that a primary care team is delivering the services. An effective consent process respects patient autonomy, recognizes the patient as a rational decision-maker capable of self-selecting advanced primary care services, defines the clinician–patient relationship in the context of advanced primary care, and creates a social contract of expected service delivery (Eleanor and Jennifer, 2016; Sheridan et al., 2004).
• Additional mechanisms to demonstrate delivery of APCM services will need to be developed for practices not participating in demonstration programs that include advanced primary care.
• Creating an annual evaluation process (e.g., evaluation of claims data; ongoing quality measurement as part of ACO, ACO Realizing Equity, Access, and Community Health (REACH), Making Care Primary, and Primary Care First; beneficiary and clinician satisfaction surveys) can help to assess if the reporting mechanisms ensure delivery of the 10 APCM elements, prevent fraud and misuse of APCM codes, and improve satisfaction and outcomes. Findings could be used to adapt future reporting mechanisms. A parsimonious set of reliable indicators, ideally that are already being collected, will need to be identified to evaluate the APCM program.
• For ACOs, CMS should consider excluding APCM spending from ACO spending totals and reducing ACO spending benchmarks accordingly, since including APCM spending in these totals could create misaligned incentives and restrict non–primary care spending.

Educating Practitioners and Beneficiaries

• Recommendation 3: The Centers for Medicare & Medicaid Services (CMS) should develop educational materials for beneficiaries and interprofessional team members to proactively teach the elements of advanced primary care and those services that should be included as part of APCM. Evidence of slow and uneven uptake of the annual wellness visit could inform an enhanced approach to disseminating educational materials and informing clinicians and beneficiaries about APCM services (Ganguli et al., 2017).

• Materials should be developed using universal design principles, follow culturally and linguistically appropriate services standards, and be available in multiple languages to promote uptake (Centre for Excellence in Universal Design, 2024; Think Cultural Health, 2024).
  • CMS could disseminate educational materials in a variety of ways (e.g., webinars, social media, YouTube, paper pamphlets) and provide a mechanism for practices to ask follow-up questions such as via a CMS call center.
  • Dissemination activities could occur at community events and national and local professional society meetings.
  • CMS could develop a standardized consent document following culturally and linguistically appropriate services (CLAS) standards (Think Cultural Health, 2024), in collaboration with patient advocates, that includes a brief description of APCM services. This could help patients and clinicians develop a shared understanding of what services will be delivered as part of APCM, and it could support the ability of CMS to standardize the process practices use to demonstrate delivery of APCM.

CMS’ REQUEST FOR INFORMATION

After describing the APCM policies and payments, CMS’ proposed rule includes an RFI with a series of questions about future primary care hybrid payment models. These hybrid payment models could build on lessons learned from experiences with APCM in 2025 and could include the bundling of more primary care services, greater prospective payments to support resources and infrastructure, and reductions in the proportion of fee-for-service payments. In the following sections, the committee responds to CMS’ RFI questions about the future of primary care hybrid payments across five topics:

1. Streamline value-based opportunities,
2. Billing requirements,
3. Person-centered care,
4. Health equity and clinical and social risk, and
5. Quality improvement and accountability.

STREAMLINE VALUE-BASED OPPORTUNITIES

Committee Response

Supporting Primary Care Clinicians and Practices New to Care Management

• Extensive evidence from federal initiatives to promote advanced primary care practice, such as the AHRQ EvidenceNOW program, indicates that smaller practices that are not part of large health systems are least equipped for practice transformation (Cohen et al., 2023). These practices are often in underresourced communities serving rural and low-income populations and can be isolated from the larger medical community. Supporting these practices is critical for improving health equity.
• In addition to ongoing APCM payments, practices new to care management may require two forms of support: (1) start-up funds to hire care management staff (Bodenheimer, 2022) and purchase information technology (IT) tools for population health, and (2) training and technical support (e.g., practice facilitation) to implement population health and care management improvement processes The Agency for Healthcare Research and Quality (AHRQ) EvidenceNOW program is an example of practice facilitation support for small and medium primary care practices and has been effective showing improved quality of care and patient outcomes (AHRQ, 2023; Huffstetler et al., 2024).
• Ensuring stable prospective payments and low documentation burden, as described with the APCM services, may also reduce barriers to participation.

E/M Services and APCM

• Recommendation 4: The Centers for Medicare & Medicaid Services should expand advanced primary care management services to also create a future primary care hybrid payment model with greater prospective payment that includes some but not all evaluation and management and relevant services.
  • Hybrid payment models supporting advanced primary care mitigate fee-for-service incentives for increased inappropriate health services use and provide resources for team-based care and non-physician fee schedule services, though this produces modest to no reductions in total health care spending and use in the short term (NASEM, 2021).
  • With adequate time, hybrid reimbursement models show improvements in care and reductions in hospitalizations and

• emergency room use, particularly for people with multiple complex chronic conditions (Maeng et al., 2016; Saynisch et al., 2021).
  • Ultimately, an APCM hybrid payment model recognizes the scope of high-quality primary care and the resources required to manage patient populations over time, but the payment amount needs to align and evolve with those resource costs. For instance, feedback from Primary Care First participants noted that payments were not adequate (Schurrer et al., 2024). Policy makers must carefully ensure that payment amounts are sufficient to make desired improvements.
  • Finally, primary care payment reform is key to attracting more U.S. physicians into primary care training and practice and thereby increasing the primary care workforce (Zabar et al., 2019).
• Strategies to prevent advanced primary care hybrid payment from reducing provider incentive to provide appropriate E/M services (and thus reducing patient access to services) include:
  • Continuing fee-for-service E/M payments for a few select types of services meriting fee-for-service incentives, such as annual wellness and home visits. While APCM payments will increase total primary care payment, they are not so large as to replace the need for E/M payments (Berenson et al., 2020).
  • To ensure that primary care continues to provide E/M services, CMS could consider a modest annual visit quota (e.g., one virtual or in-person visit per year) as part of the hybrid service model, which could also serve as an opportunity for verifying patient consent and attribution to the primary care clinician.
  • Tracking of measures on access, comprehensiveness, continuity, coordination, and patient-centeredness can help to identify deficiencies that may result in excluding the provider or practice from continuing in the advanced payment model (see more on measures in the “Quality Improvement and Accountability” section below).

Incorporating Other Communication Technology-Based Services

• Remote physiologic monitoring is beneficial for certain medical conditions, such as hypertension, diabetes, and obesity. CMS could consider incorporating remote physiologic monitoring and/or remote therapeutic monitoring into advanced primary care hybrid payments. While incorporating these services into primary care is promising, more implementation and effectiveness research is

• needed and the cost to implement the services would need to be calculated (Damani, 2024; Serrano et al., 2023; Tang et al., 2022). Theoretically, enabling primary care to offer these services could help keep care local and close to home, especially for rural residents (NASEM, 2024) and increase access to care for patients with transportation challenges (e.g., older adults, people with functional limitations) (Ganguli et al., 2023).
• The expansion of wearable devices for patients to monitor their vital signs can be incorporated into existing electronic health records (EHRs), and patients can initiate encounters with their primary care clinician to advise on the findings. There is evidence to support ambulatory blood pressure monitoring (Krist et al., 2021), but other wearable devices will require more evidence about how to use these data to improve outcomes for patients (Peyroteo et al., 2021) without contributing to clinician burnout.

Alternatives to the Relative Value Scale Update Committee for Valuing Primary Care Services

• Recommendation 5: The Centers for Medicare & Medicaid Services should rely on empirically collected data for time and practice expense calculations to help determine hybrid payment rates rather than information presented by the Relative Value Scale Update Committee (RUC) (NASEM, 2024). The RUC relies heavily on provider-reported surveys that are subject to bias (Berenson and Hayes, 2024; MedPAC, 2024; Zuckerman et al., 2016), are based on small samples of specialty society members, and tend to place higher value on the specialty-based procedural codes while undervaluing the cognitive services delivered by primary care involved in the data gathering, analysis, decision making, care coordination, and management of E/M codes (Berenson and Goodson, 2016). Diversifying data sources and increasing the transparency of the process would enhance the accuracy, equity, and comprehensiveness of payment rates (McMahon and Song, 2024).
  • Ideally, a committee compliant with the Federal Advisory Committee Act would oversee the process of compiling and submitting relevant data to CMS to inform its valuation decisions. This would help ensure the transparency of the decision-making process, enable a mechanism for public input, reduce subjectivity, and restore public trust in the valuation decision-making process (Berenson and Hayes, 2024; GAO, 2015; NASEM, 2024).
• Recommendation 6: When determining the relative value and resources of primary care services for setting hybrid payment rates,

• the Centers for Medicare & Medicaid Services should account for the time and tasks spent on the electronic health record (EHR) for delivery of high-quality primary care services. Consistency between the direct observation findings, physician self-reported EHR work, and EHR system-event log data supports consideration of user-event log data as an accurate tool for assessing EHR activities associated with both direct patient care and asynchronous work during and after clinic hours (Arndt et al., 2017).
• Primary care physicians spend the most time on the EHR of any specialty, spending nearly 2 hours on EHR tasks per every hour of direct patient care (Arndt et al., 2017; Rotenstein et al., 2023) and an additional 1.5 hours per day outside of clinic hours (Arndt et al., 2017).
  • Patient portal tasks are one of many time-consuming EHR activities critical to facilitating care coordination and the management of patients with chronic conditions but are not typically compensated (Rotenstein et al., 2023). CMS should account for patient portal tasks in hybrid payment models (Berenson et al., 2022; NASEM, 2024).
  • Lack of compensation for EHR-based primary care work also contributes to gender inequities in primary care payment, which in turn threatens sustainability of the primary care workforce (Ganguli et al., 2022a,b).
  • CMS should use EHR data extracts to audit patterns of time spent by primary care physicians on treatment pathways, preventive care strategies, and the management of chronic diseases. Further details can be obtained through EHR “event logging” to value the time spent on documentation, responding to patient portal messages (i.e., sending and receiving clinician, staff, and system messages), clinical review, and placing orders (Rotenstein et al., 2023). Administrative tasks that can theoretically be delegated to other care team members and are not related to patient care should be valued less than patient care activities. However, these tasks are time consuming and should be accounted for appropriately.
  • CMS should use EHR data extracts to review time incurred from clinical staff (e.g., nurses, population health managers, community health workers, peer-support specialists, paid caregivers) to support the true value of the code-specific task (Berenson et al., 2022).
  • EHR audit data should also be used to understand how factors beyond social risk contribute to time spent in primary care work. For instance, Hierarchical Condition Category risk scores

• are poor proxies for primary care work, as they were designed to predict total Medicare spending, which is driven by inpatient care (Ganguli et al., 2022b); instead, alternative clinical and sociodemographic factors should be identified that more closely correlate with primary care work. These may include comorbid mental health and chronic health conditions that are typically managed in primary care settings and factors associated with greater care-seeking behaviors via patient portals.
• Comprehensiveness is a key indicator of the relative value of primary care service (Starfield, 1979), with more comprehensiveness being associated with less care fragmentation, better health outcomes, and lower cost (O’Malley et al., 2019). Claims-based measures have been used to track comprehensiveness but are limited in identifying the degree to which the primary care physician is truly managing the condition listed on the claim (O’Malley and Rich, 2015). EHR data within clinical notes would optimally be included when measuring comprehensiveness but are often not included owing to burdensome challenges with EHR chart abstraction (O’Malley et al., 2019). Large language models (LLMs) and artificial intelligence have shown promise in overcoming previous manual chart abstraction methods (Ge et al., 2024). CMS should consider future research on the use of LLMs to capture the degree of PCP comprehensiveness within EHR clinical note abstraction to inform hybrid payment rates.

BILLING REQUIREMENTS

Committee Response

Attribution

• Recommendation 7: The Centers for Medicare & Medicaid Services should attribute the advanced primary care clinical episode to a single clinician recognizing that continuity of care and practice-level factors contribute to patient outcomes in team-based models.
  • While team-based approaches are necessary to deliver advanced primary care, higher continuity of care with an attributed provider is associated with lower health care use and costs (Nicolet et al., 2022) and patients also value having a main point of contact for their health care needs (Fan et al., 2005; Nutting et al., 2003).
  • Because attribution is essential for payment and to create accountability for care and cost, accurate attribution is needed. However, there is limited evidence about the best way to define attribution to groups of clinicians, individual clinicians, or

• hospitals through billing data (Lewis et al., 2013; Scott et al., 2011).
• The CMS requirement to obtain and document patient consent for APCM participation could be used for attribution in hybrid payment models as well. Consent material should clarify that only one clinician and their interprofessional team can provide APCM services during a single attribution period. If an annual visit is considered part of bundled hybrid services (see the committee response to the “Streamline Value-Based Opportunities” section above), annual continuity of care for this visit could ensure ongoing attribution.
• Recognizing that a team-based approach is required for high-quality primary care (NASEM, 2021), it is important to highlight that advanced primary care may intentionally require visits with more than one advanced primary care team member at the same location on the same day and over time (Porter et al., 2023). Accordingly, hybrid payments may be allocated in various ways at the practice level depending on the specific nature of the shared work. This will support both individual clinician and practice-level primary care continuity, both of which are associated with improved outcomes (NASEM, 2021; Rodríguez and Zink, 2021; Yang et al., 2022).

Reducing Billing Burden

• To reduce billing burden, CMS should use similar approaches to what they propose for reducing documentation burden with APCM services (see the description of APCM earlier in this document). Additionally, once a patient is enrolled in hybrid payment services, monthly payment could be automatically paid, without the need for monthly billing for 1 year. Annual consent and documentation of consent could occur at the proposed annual visit to continue the hybrid payment. At any point prior to the end of the year, either the clinician or patient could report to CMS a cessation of services, and monthly payments would cease. Similar to APCM payments, CMS could consider making future hybrid payments to one attributed clinician in any period.
• Targeted educational programs and feedback on billing errors can ensure uptake of hybrid payments and accurate and efficient billing by clinicians and practices. Prior Medicare physician fee schedule billing code changes such as the Medicare annual wellness visit, transitional care management, and chronic care management codes had limited early uptake (Agarwal et al., 2018; Ganguli et al.,

• 2017) and disproportionate adoption by already well-resourced practices serving fewer marginalized patients (Ganguli et al., 2017, 2018).
• Use of tools within the EHR can take advantage of LLM review of documentation to bill accurately and reduce the need for retroactive payment adjustments (see discussion of LLM in the committee response to the “Streamline Value-Based Opportunities” section above). As this is an emerging field with new applications coming to market on a near daily basis, a thoughtful approach to how to incorporate this into existing EHRs or in a separate electronic system is needed as well as further research (Kilanko, 2023; Yang et al., 2023).
• Quality measurements should be minimal in number, reflect the core functions of primary care, generate the evidence needed to design APCM and hybrid payments that improve outcomes, and rely on claims-based administrative data where possible. Claims-based measures of continuity and comprehensiveness are available and validated (O’Malley et al., 2019; Pollack et al., 2016). Patient and practice self-report metrics are burdensome to collect, but can be useful for key essential measurements (see “Quality Improvement and Accountability” section below).

Cost Sharing

• Recommendation 8: The Centers for Medicare & Medicaid Services should waive cost sharing for APCM and future hybrid payments that are critical for delivering high-value advanced primary care. Granting CMS the authority to do this will require legislative action.
  • Cost sharing is a barrier to access to medical care among Medicare beneficiaries and results in inequities in care. In 2017, 11 percent of Medicare beneficiaries reported delaying care because of worries about costs, with low-income beneficiaries having twice the odds of delaying care as beneficiaries who had higher incomes (Madden et al., 2021). Although the Affordable Care Act prohibits cost sharing for preventive services (ASPE, 2022), this does not apply to all the other services delivered in primary care, such as care of chronic conditions. The evidence suggests that cost sharing for APCM and hybrid services billed on a fee-for-service basis would inhibit many beneficiaries from consenting to services, especially those with lower incomes who do not have cost sharing covered by Medicaid as a secondary payer (Madden et al., 2021). This would in turn be a barrier to primary care practices providing these advanced primary care services if many beneficiaries declined consent.

• To the extent that some cost sharing may be required from some beneficiaries for monthly APCM and future hybrid fees, CMS should consider providing anticipatory guidance to beneficiaries that makes clear both the benefits of having a “personal doctor” and the expanded services to be delivered. CMS could also consider a sliding scale or waiving cost sharing for lower-income beneficiaries who lack a secondary payer; however, this would require additional authority that CMS currently does not have.

PERSON-CENTERED CARE

Committee Response

Activities to Include in the Hybrid Payment Model

• Recommendation 9: In future hybrid payment models, the Centers for Medicare & Medicaid Services should include the following

• categories of services in a bundled monthly payment: (1) the APCM services described above; (2) an annual wellness visit or chronic care management visit to create personalized care plans and to establish attribution; (3) additional care management services, communications, and interprofessional team member services not currently reimbursed under fee-for-service; (4) a fixed number of behavioral health and social care visits; and (5) informatics for remote monitoring, telehealth, and advanced analytics services.
  • The APCM services proposed for CY 2025 include many services needed for advanced primary care practices and can serve as a foundation for the services included in future hybrid payment models (NASEM, 2021). This includes risk stratification of patients, population health approaches to make care more proactive, and communications outside of the office visits between patients and their clinicians (such as e-mails, phone calls, and messaging patients and caregivers via portals).
  • The current annual wellness visit or a dedicated chronic care visit could be included in the future bundled hybrid payment. This visit could provide the clinician and patient dedicated time to create a personalized care plan, inform the patient about services included in hybrid services, and obtain consent for participation (Beckman et al., 2019; Lesser et al., 2011). This could also support the attribution process (see the committee response in the “Billing Requirements” section above). One visit for this approach would be mandatory for the hybrid payment. Additional visits would be billed via E/M codes for the full hybrid model.
  • Patients in advanced primary care practices will likely benefit from additional services delivered by the core primary care interprofessional team and not included by current E/M codes, such as filling out paperwork for patients, completing prior authorizations, and reviewing records to coordinate care and identify needs. These activities are time consuming and disproportionately affect primary care compared to other specialties (AMA, 2024; Rao et al., 2017).
  • Some patients may also need other services delivered by extended primary care team members and not traditionally included in E/M codes that could be bundled into future hybrid payments including pharmacist care, patient navigation, social work support, peer support, community health worker assistance, and nutritional and other health behavior counseling supports. These services are essential primary care services but are not included in current payment models or not reimbursed

• adequately to ensure uptake (Galewitz and Hacker, 2024; Hartnett et al., 2023; Holtrop et al., 2015; Ma et al., 2022; O’Malley et al., 2017; Rotenstein et al., 2021).
• Behavioral health and social care are core services for advanced primary care practices. Care and payment for these services are often siloed, but integrated behavioral health and social care have been shown to improve outcomes (NASEM, 2023). Hybrid payments can support infrastructure and interprofessional team members (Miller et al., 2017). Additional E/M payments for these services will be needed for individuals with more intensive needs.
• Each primary care practice across the country serves a unique community with unique needs and finite resources so interprofessional team composition will need to vary greatly across settings (NASEM, 2021). Additionally, similar to APCM services, patient needs would likely vary over time. Any type of hybrid payment model should allow for flexibility in services and interprofessional team-based delivery and not expect delivery of all services for all patients. Patients with complex medical needs may need access to routine treatment and care management services that are provided by clinicians outside of their core primary care team delivering APCM services.
• Expanding services included in future hybrid payment models will require increased payment compared to the proposed APCM payments, and continued payment for E/M services will remain important for more intensive service delivery. See responses throughout this report about strategies to value additional services.
• As future hybrid payment models are developed continuing the APCM payment model or other bundled payment, options for tracks or tiers of participation will be needed, as all practices interested in participating may not be able to offer all bundled services (e.g., behavioral counseling, social needs).

Ensuring Access to Care via Telephone and Messaging

• Telephone and messaging services are essential for 24/7 access and are included in the proposed APCM services. Continuing to include these services in future hybrid payment models will help to ensure access.
• Accurate estimation of time and effort primary care teams spend on these activities (with proper adjustments such as patient population, panel size, and region) to ensure appropriate infrastructure support through payment will incentivize practices to participate in the

• APCM and hybrid models and sufficiently deliver telephonic and messaging services (see the committee’s response to the “Streamline Value-Based Opportunities” section about estimating resources).
• As described in the committee’s response to the APCM section, informing patients about telephone and messaging access, by CMS through educational and promotional materials and by clinicians through the consent process, can create a shared understanding about what the service entails. Patients who feel they are not receiving any required services from their advanced primary care team could cancel their participation in the APCM or hybrid payment program.

Structure Advanced Primary Care Hybrid Payments to Improve Patient Experience and Outcomes

• Helping patients understand the advanced primary care services included with APCM and hybrid models of care has the potential to improve patient satisfaction with care. Patients report that challenges accessing primary care affect satisfaction (Rose et al., 2023). The proposed APCM services, if delivered well, should improve access to care.
• Ensuring that the services included in future hybrid models are evidence-based will help to ensure that hybrid model programs improve outcomes for patients.
• Measuring the quality of APCM services (see “Quality Improvement and Accountability” section below) can support evidence-guided adaptation of future APCM and hybrid policies and payments to further promote satisfaction and improved outcomes.

HEALTH EQUITY AND CLINICAL AND SOCIAL RISK

Committee Response

Risk Factors, Adjustment, and Metrics

• Recommendation 10: The risk adjustment method for the proposed hybrid payment model should include a few basic demographic characteristics such as age and gender and heavily weight social factors predictive of high need for primary care services (Huffstetler and Phillips, 2019; NASEM, 2017) using place-based measures and geocoding of beneficiary residence to assign small area (e.g., census block) measurements of social factors to the individual beneficiary. Incorporating social risk factors should only be considered if it leads to an upward adjustment to the base payment to ensure that resources are adequate to meet needs.
  • While patient-reported data are highly valued by patients and federal agencies, they are not universally or uniformly collected (National Quality Forum, 2020). Given this challenge, place-based measures may be more reliable and consistent (Berkowitz et al., 2015) and ensure that the data used for decision-making reflects the population’s needs. Using place-based measures in combination with patient self-report can also potentially reduce bias, as place-based measures offer an additional objective data point documenting the risks of covered patients.
  • The risk adjustment method should not replicate the Hierarchical Condition Category/Risk Adjustment Factor method used by CMS for adjusting payment to Medicare Advantage plans and for other risk-sharing contracts. This method was not designed to predict primary care service use and has proven to be susceptible to manipulation to inappropriately increase CMS payments to Medicare Advantage plans (MedPAC, 2024).
  • The risk adjustment model should be developed to reflect primary care service needs (behavioral health, physical health, and social health), not to predict total costs of care. The goal of the new payment method is to fairly compensate primary care teams for comprehensive primary care services and to recognize the powerful influence of social drivers of health care need. The adjustment model should focus on predictors of need for appropriate primary care services and not impose a financial risk for total costs of care.
  • While social factors predict high need for primary care, they are also associated with barriers to accessing primary care, resulting in lower observed use of primary care than predicted (McWilliams et al., 2023). Advanced primary care practices

• serving communities at social risk will need to proactively reach out to people in need of services, which will take additional infrastructure and resources (Ganguli et al., 2021).

QUALITY IMPROVEMENT AND ACCOUNTABILITY

Committee Response

Key Patient-Centered Measures of Quality, Outcomes, and Experience

• Recommendation 11: To capture patient experience and patient-reported outcomes, the committee recommends using the validated, patient-reported Person-Centered Primary Care Measure (PCPCM PRO-PM) (AMA, 2022; American Academy of Family Physicians,

• 2022; Etz et al., 2019). The PCPCM PRO-PM is a reliable, comprehensive, and parsimonious measure of the high-value tenets of primary care, as assessed by the patient (AMA, 2022; Etz et al., 2019). The PCPCM PRO-PM is included in the CMS Innovation Center’s Making Care Primary demonstration model (CMS, 2023).
  • Additionally, the currently used Consumer Assessment of Healthcare Providers and Systems survey could be updated to include patient experience questions related to team-based care in the ambulatory primary care setting to better understand how team-based delivery can affect service use.
• Recommendation 12: While clinical quality measures are critical to include, the committee recommends prioritizing measures of the key functional attributes of primary care (e.g., continuity, comprehensiveness, coordination, and access) and the value of services received (selection of a small set of high- and low-value services) rather than only using disease-specific quality measures. This approach was supported by Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021).
  • Continuity of care (Merenstein, 2021; NASEM, 2021) and comprehensiveness (O’Malley et al., 2019) have been linked to decreased downstream health care use and costs (Bazemore et al., 2015, 2018). A continuity measure is included in the Merit-based Incentive Payment System (measure ID: ABFM12, CBE #3617)^6,7 and could be considered.
  • Comprehensiveness refers to the extent to which a primary care team recognizes and meets most of a patient’s health care needs (O’Malley et al., 2019). Increased comprehensiveness has been linked to decreased emergency department visits, lower hospitalization rates, and decreased Medicare expenditures (Bazemore et al., 2015). A comprehensiveness-of-care measure is being reviewed for national endorsement this year, and depending on the outcome, could be considered (Center for Professionalism and Value in Health Care, 2023).
• Recommendation 13: To identify and ultimately help reduce disparities, the committee recommends that equity also be included as an additional measure of quality by stratifying data by race, ethnicity, disability (independently and in interaction), place of residence, and other characteristics.
  • The Institute of Medicine’s 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century identified

___________________

⁶ See https://qpp.cms.gov/mips/traditional-mips (accessed August 21, 2024).

⁷ See https://p4qm.org/measures/3617 (accessed August 21, 2024).

• equity as a key domain of quality (IOM, 2001), and this committee feels it is critical to include to help ensure that high-quality primary care is accessible to all. The measure could incorporate creative strategies to address health inequities with several practical examples documented (Anderson et al., 2018).
• Clinical measures should disaggregate data to identify disparities that may exist across demographic categories, such as race and ethnicity, disability status, rural or urban location, and geography. This provides more focused insight into the effect of services across groups of service recipients (National Academy of Medicine, 2022).

Promoting Alignment Across Payers for Advanced Primary Care Services

• Payer alignment will be essential for primary care to deliver advanced primary care and transition to hybrid payment models. As described in Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021), transformation to advanced primary care occurs across an entire practice and is not limited to a subset of patients. Funding for advanced primary care for a subset of patients alone will be insufficient to fund practice transformation. It is also unethical for some payers and patients (through cost-sharing mechanisms) to pay for advanced primary care services while others receive the services at no cost, with the exception of need-based determinations (e.g., qualified Medicare beneficiaries).
• Lessons learned from the CMS Innovation Center’s CPC+ program, which sought multipayer participation, with limited success, could inform future approaches (Mathematica, 2023; Singh et al., 2024).
• CMS could encourage hybrid payments in Medicaid by releasing additional guidance regarding implementation of hybrid payments in fee-for-service delivery systems, continuing efforts to involve state Medicaid agencies in the early stages of model design, and/or creating waiver flexibilities or a specific demonstration waiver for hybrid payments (Houston et al., 2022). Removing or waiving requirements to reconcile prospective payments to fee-for-service, as noted in the RFI, has been identified as important for predictability and stability of payments.
• Demonstrating improved patient satisfaction, quality, and outcomes as well as primary care workforce, access, and care delivery from the proposed 2025 APCM program may give other payers an incentive to participate.

• There are many state-level initiatives and legislative activities to increase investment in primary care (Maryland Department of Health, 2024; Polsky et al., 2015; Purchasers Business Group on Health, 2024; Virginia Center for Health Innovation, 2024). Collaborating with these state initiatives to support and promote APCM and hybrid payments as a strategy to invest in primary care could promote payer alignment.

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