The Simple Truth About Primary Care’s Complexity

Let’s talk about unity first.

The AAFP — alongside health organizations representing more than a million clinicians — started 2023 by asking Congress to comprehensively reform Medicare payment. Do it this year, we all said.

Then, in the spring, lawmakers moved in that direction by introducing bipartisan legislation to ensure annual inflation-indexed increases to the Medicare physician fee schedule’s conversion factor. The Academy rallied behind the bill together with scores of other physician groups. 

Neither that bill nor any other congressional reform everyone in the house of medicine wants has passed yet this session. Unfortunately, this has left a big opening for the 2024 Medicare physician fee schedule and Quality Payment Program proposed rule (published last month; the AAFP’s summary for members is here, and I’ll go over its high points in a minute) to divide clinicians. 

G2211: What Is It, and Why Is It Drawing Fire?

One of the worst side effects of Medicare’s inadequate physician payment system is that its outdated mechanisms bring medical specialties into conflict with one another. This has too often been the case in recent years, and it’s happening again now because of an add-on code — G2211 — that’s meant to more appropriately pay for primary care visits. CMS plans to fully implement this code in 2024. We strongly support G2211, which would be billed alongside office/outpatient evaluation and management codes.

CMS says Code G2211 describes “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

In other words: the continuous, comprehensive, coordinated primary care that family physicians give their patients — for which Medicare has historically underpaid.

CMS finalized G2211 in 2021, but Congress halted its implementation until Jan. 1, 2024. Lawmakers balked because CMS initially estimated the code would have high usage, which would have to be offset with payment cuts elsewhere in the fee schedule. (Instead, Congress passed conversion-factor relief for all physicians, which still benefited AAFP members.) The reason for this is budget neutrality: the stipulation that CMS can’t raise payment in any area of the fee schedule without lowering it somewhere else. Congress, the Academy has long argued, must fix this outmoded mandate, which stifles investment in primary (and other medical) care and fails beneficiaries. 

The good news about the proposed 2024 MPFS is that it does what we’ve spent the past two years urging CMS to do: recalibrate that unrealistic utilization estimate for G2211. The MPFS’ updated, far lower estimate for the cost of implementing G2211 is by itself a significant win for the Academy. Now we need Congress and CMS to stick to the plan and activate this powerful investment in primary care practices and their patients. 

But as Politico recently noted in coverage that quoted the Academy’s advocacy, 19 surgical groups have vowed to fight G2211, claiming it will harm surgeons and overpay primary care clinicians. This posture forgets that primary care is the bedrock on which referrals are built. It ignores that family medicine office visits really are more complex than those provided by other specialties, and that better payment for primary care services can improve patient health while promoting care continuity that reduces mortality, health care expenditures and hospitalizations.

We are already taking forceful action to ensure that such inaccuracies about G2211’s function and importance do not stand. I encourage you to join this push by using our Speak Out tool to contact your members of Congress directly.

The enemy here is budget neutrality, not a proposal to improve comprehensive, accessible, affordable primary care for Americans. The enemy is the statutory framework turning this annual rulemaking into a zero-sum fight. That’s why the Academy, together with groups representing hundreds of thousands of other clinicians across specialties, has repeatedly asked Congress to reform the budget-neutrality requirement and fix this broken system.

What Else Is in the 2024 MPFS?

Let’s do some math.

The proposed conversion factor for 2024 is $32.75. This marks a 3.36% reduction from the 2023 conversion factor (the amount Medicare pays per relative value unit), thanks to budget neutrality adjustments and the partial expiration of 2023 conversion factor relief. Together, this conversion factor reduction and the benefits of G2211’s full implementation would mean, we estimate, about a 2% increase to family physician pay.

Again, then: G2211 is a significant win for primary care, one we have advocated strongly for and one we will wholeheartedly fight to keep.

Even with the more realistic utilization estimate we and others called for, however, CMS says that expected use of G2211 accounts for 90% of the proposed MPFS’ overall budget neutrality adjustment in 2024. It’s this number that has other medical groups sharpening their scalpels for primary care.

Beyond that, the proposed rule includes other wins for family physicians, including 

• a significant increase to the value of the general behavioral health integration code (CPT 99484), supporting improved access to such care in line with our advocacy;
• updated clinical labor pricing, which began in 2022 following our advocacy;
• payment for some telehealth services furnished to patients in their homes at the higher non-facility rate;
• implementation of all the telehealth extensions enacted in last winter’s AAFP-favorable omnibus spending bill;
• permission for supervising physicians to use audio-video technology to supervise resident physicians through the end of 2024, as we’ve urged;
• new coding and payment for social determinants of health risk assessments; and
• an indefinite pause on implementation of the Medicare appropriate use criteria program, as we’ve called for. 

To maximize the impact of these advances, though, Medicare payment must be reformed. So we continue to ask Congress to enact an annual inflationary update so that Medicare allows all physicians to keep pace with rising practice costs. 

What’s next?

Congress, as has been widely reported, adjourned for August recess without resolving a number of big health care issues, including Medicare payment. We expect movement on several of these things in September with bill packages addressing our workforce priorities as well as transparency legislation including a potential win for us on prior authorization.

That means this is an optimal moment for AAFP members to reach out to their delegations and tell them your concerns. I can’t overstate how important it is for you to add your voice to our advocacy while your lawmakers are back home. Meeting with your members of Congress is not hard, and the AAFP can help you. I also urge you to sign onto our related Speak Out campaigns.