2024 MPFS: AAFP Presses for Greater Primary Care Investment

Agency Should Use ‘Many Regulatory Levers,’ Work With Congress

Sept. 21, 2023, News Staff — The AAFP’s detailed response to the proposed rule for CMS’ 2024 Medicare fee schedule and Quality Payment Program identified the limits of what regulators could do to bolster primary care in a fee-for-service environment — then urged the agency to join lawmakers and push past that boundary.

The AAFP’s championing of G2211 includes renewed congressional advocacy to address the underfunded, outdated Medicare physician payment laws that mandate annual payment cuts and require CMS to reduce payments for other services provided by family physicians to offset this important investment in primary care.

“Evidence demonstrates the continuous, comprehensive and coordinated primary care services family physicians provide are more complex and comprehensive than other types of office visits,” the AAFP told CMS. “While the updated office/outpatient E/M codes more appropriately value the care provided during an office visit, the existing processes for creating, describing and valuing these codes do not account for unique resources borne by primary care and other physicians providing longitudinal, patient-centered care. Thus, G2211 is needed to appropriately value primary care and other types of longitudinal care relative to other services in the fee schedule.”

Primary Care Investments

Beyond G2211, the AAFP recognized several proposals in the rule that would “support the provision of comprehensive, whole-person primary care,” including

• new coding and payment for screening and addressing unmet social needs and
• more accurate payment for behavioral health integration, in line with the AAFP’s advocacy.

“The Academy strongly supports the proposal to create coding and payment specifically for Community Health Integration services, which would allow primary care teams to address a patient’s social determinants of health needs with support from a community health worker,” the letter said. The rule as written would also allow separate Medicare payment for SDOH needs assessments, services that many family physicians provide now without reimbursement.

The letter welcomed the proposed rule’s addition of Principal Illness Navigation services for patients with a serious, high-risk illness who would benefit from support managing the social aspects of a severe illness.  

“We applaud CMS’ efforts to identify and value the growing number of services that primary care physicians deliver to patients, but we also surge CMS to implement new payment strategies that are better positioned to support the delivery of comprehensive primary care services,” the Academy added.

The AAFP also supported proposed payment increases for general behavioral health integration services. Noting that family physicians regularly work with psychiatrists, psychologists, licensed clinical social workers and other behavioral health professionals to provide behavioral health care, the letter said the proposed rule stands to “ensure family physicians and other primary care physicians can utilize a care team that best fits the needs of their practice and patient population.”

Despite this advance, though, the Academy cautioned that startup costs and other challenges continue to prevent greater integration of behavioral health care into primary care practices.

“We urge CMS to work with Congress to enact legislation to provide robust financial support for behavioral health integration outside of the confines of MPFS budget neutrality requirements,” the letter said.

To realize the full benefits of these and related primary care investments in the MPFS, the Academy said CMS and Congress should work together to address the persistent problems with Medicare law that lead to annual payment cuts, pitting specialties against one another, and worsening administrative workloads and physician burnout.

“We recognize that CMS does not have the authority to address many of the challenges detailed here,” the AAFP said. “Nonetheless, CMS has demonstrated that it has many regulatory levers to bolster support for and equitable access to primary care, including by correcting historic imbalances within the MPFS and advancing primary care–led alternative payment models. We urge CMS to continue this vital work by continually investing in primary care in the MPFS and across other programs.”

Telehealth

The AAFP applauded the proposed rule’s policies advancing the payment and delivery of telehealth services rendered by family physicians following the end of the public health emergency, including the extension of pandemic-era telehealth flexibilities required by the Consolidated Appropriations Act of 2023. The rule as written also would pay telehealth services billed with POS 10 (patients at home) at the higher nonfacility rate, in line with the AAFP’s advocacy.

To complement this progress, the AAFP urged CMS to work with Congress to enact AAFP-backed legislation, such as the Protecting Rural Telehealth Access Act, to permanently remove geographic and originating site restrictions and expand the definition of a telecommunication system to include audio-only technology. The letter further repeated the AAFP’s strong recommendation that HHS permanently expand the primary care exception to include an array of codes, including several covering behavioral counseling.

Vaccines

Echoing recent guidance the Academy sent HHS about the transition of COVID-19 vaccines to the commercial marketplace, the Sept. 6 letter called on CMS to clarify that the enhanced vaccine administration payment for COVID-19 (which is tied to the  FDA’s ongoing emergency use authorization declaration) will continue through 2024, as has been widely assumed. This specificity is necessary to avoid adding financial and operational challenges to family medicine practices, the AAFP said; a higher payment rate for COVID-19 vaccine administration would likewise reflect the higher costs associated with acquiring and storing COVID-19 vaccines, as the Academy has long said.

The Academy thanked CMS for basing annual updates of Part B vaccine administration payment rates on increases to the Medicare economic index, adjusted for geography. “The AAFP continues to advocate for an annual inflationary update tied to increases in the MEI to be implemented for all services under the MPFS, but we appreciate CMS using its authority to apply it here,” the letter said.

The AAFP also expressed support for the rule’s proposed extension to all Part B preventive vaccines the additional payment for in-home administration of COVID-19 vaccines established during the PHE. This change would further reward the Academy’s advocacy win on that front.

Noting that the Medicare Payment and Access Commission has repeatedly recommended covering all preventive vaccines under Medicare Part B, the Academy called on CMS to work with Congress to enact Medicare Part B coverage and payment for all vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (such as those for shingles and RSV) so that all beneficiaries can access these vaccines from their trusted primary care physician instead of having to be referred to a pharmacy.

Appropriate Use Criteria

In line with the Academy’s advocacy, the rule would pause indefinitely implementation of the Appropriate Use Criteria program, a move the letter applauded.

The program was established by the Protecting Access to Medicare Act of 2014 and was designed to reduce unnecessary orders for diagnostic imaging. The AAFP and numerous health care stakeholders have long called it burdensome and complex.

“The program also does not consider quality, patient outcomes or other important factors, which are more appropriately addressed in alternative payment models,” the Academy wrote. “According to an AAFP survey, more than half of our members report participating in an APM. These physicians are already accountable for the quality and cost of their care, including strong incentives to reduce unnecessary utilization of costly imaging services, rendering the AUC program unnecessary.

“The AAFP thanks CMS for being responsive to our recommendations, and we strongly urge CMS to finalize this proposal to delay implementation of the AUC program and rescind related regulations.”

Medicare Shared Savings Program

The Academy’s letter praised CMS for generally improving MSSP — the only permanent and nationwide APM — adding that “many of the proposals in the rule advance payment policies to support physician-led team-based care.”

But the letter objected to the rule’s proposal to align accountable care organization reporting with MIPS Promoting Interoperability, “because it would create additional reporting burdens for ACOs,” undercutting APM participation and recruitment.

In response to a request for information on more advanced participation options for MSSP ACOs, the Academy reiterated recent advocacy to implement a participation option that provides prospective, population-based primary care payments. “We encourage CMS to implement a hybrid payment option that includes primary care capitation available to all risk tracks in MSSP as a necessary step for CMS to fully realize the benefits of the program and achieve its beneficiary goals, particularly for those with high needs or in underserved areas,” the letter said.  

Quality Payment Program

The AAFP objected to the proposed increase to the Merit-based Incentive Payment System performance threshold to 82 points, saying the move could “further destabilize physician practices, accelerate consolidation and ultimately worsen access to care for beneficiaries.” This statute-dictated threshold increase, alongside the impending expiration of the Advanced Alternative Payment Model bonus, would “undermine progress toward value-based payment models that provide clinicians with the support and flexibility they need to deliver better care at lower costs,” the Academy said.

Citing CMS estimates that the threshold increase would result in more than 60% of small and medium-sized practices receiving a penalty, the Academy added that MIPS uses money from these penalties to fund positive adjustments for clinicians working in large health systems — evidence that the MIPS program “is not driving continuous quality improvement and is instead on a path that will accelerate the closing and consolidation of small physician practices.”

The letter asked CMS to use its available authority to prevent the damage that could occur from an increased threshold. 

The AAFP supported CMS’ proposal to combine two MIPS Value Pathways into one primary care–focused MVP, saying the move could reduce the administrative complexity of selecting and reporting to MIPS. But the letter also cautioned against CMS’ increasing use of composite measures in MIPS, given that these depend on data collection, reporting, interoperability of immunization registries and other systems that are not always reliable and which burden physicians with tracking down data.

Alternative Payment Models

Beginning with the 2024 QP Performance Period, CMS proposes to make all QP determinations at the individual level in an effort to enable more clinicians to meet the threshold. 

The AAFP cautioned that, while well intentioned, this alteration “could serve as a disincentive for specialists to participate in an AAPM, since it will make it more difficult for them to reach QP status.” CMS should instead calculate both the entity-level and NPI-level and use whichever calculation is more advantageous to the eligible clinician, the letter said.

“We also encourage CMS to work with the AAFP and others to support legislation such as the Value in Healthcare Act that would extend the AAPM bonus and allow CMS to adjust the QP thresholds through rulemaking and make varying thresholds and scaled incentive payments.”