A National Academies of Sciences, Engineering, and Medicine committee will develop a written response to questions for public input included in the Centers for Medicare & Medicaid Services' (CMS) request for information related to primary care, part of its CY 2027 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies proposed rule.
The committee will produce a report with recommendations in response to the following topics in CMS' request for information in its proposed rule:
1) Reconsidering relative primary care payment in the Medicare Physician Fee Schedule
a. What updates to the Healthcare Common Procedure Coding System (HCPCS) code G2211 should CMS consider to ensure that clinicians billing G2211 (or its modifiers) is in the best interest of beneficiaries and is considering preventative care, risk factor reduction, and other services necessary for coordinating care of beneficiaries with complex conditions?
b. What guardrails should CMS consider to prevent inappropriate billing?
c. Given the broad range of changes CPT makes annually, CMS recognizes updates to the CPT code set to reflect distinctions among O/O E/M visits by the function of the visit (longitudinal, acute, or consultative) may have significant advantages within the current billing and coding ecosystem. However, absent a change in CPT coding, should CMS consider the possibility of creating G codes to better recognize distinction between and among these kinds of visits? If so, what categories should CMS consider? How could CMS effectively differentiate longitudinal care visits from acute care visits? What number of levels would be needed and for which settings of care? Should CMS use existing CPT codes as templates?
d. Given the series of CMS Innovation Center PPCP model tests, how should CMS approach establishing PPCP in the Shared Savings Program, and more broadly across Original Medicare?
e. Are there specific data on the resources used in furnishing advanced primary care, which incorporates population health management, enhanced communication technology, and longitudinal care management? We welcome submission of any such data.
2) Payment implications of technology-enabled primary care
a. Which, if any, annual wellness visit (AWV) components are being delivered (or could be) more efficiently delivered through technology and clinical AI-enabled tools? Which activities require direct involvement by a physician, qualified non-physician practitioner, or medical professional under physician supervision?
b. In what circumstances should CMS consider payment or policy changes that would allow technology-enabled organizations, including AI technology companies, to participate in Annual Wellness Visit delivery models, either directly or through partnerships with Medicare-enrolled providers or suppliers?
c. How should CMS evaluate whether AI-enabled AWVs are improving outcomes rather than merely increasing AWV volume, documentation completeness, coding intensity, or low value care follow ‘cascades’ of services? Specifically, for which outcomes should CMS hold technology companies accountable?
3) Establishing prospective primary care payment in the Medicare Shared Savings Program
a. Should capitated payments be paid to ACOs and distributed downstream to ACO participants, or should CMS make payments directly to ACO participants that provide primary care services, similar to how CMS makes payments for APCM services, and what are the implications of each approach? Should CMS consider alternative mechanisms for delivering capitated payments directly to ACO Participants that are also primary care practices participating in Shared Savings Program ACOs? If so, what payment design, infrastructure, and policy considerations should guide the development of such alternative payment mechanisms?
b. What services should be included in primary care capitation (to accurately capture an appropriate scope of primary care services furnished to beneficiaries, balancing the importance of providing up-front flexible payments, with the potential for risk to practices if service utilization grows?
c. Should CMS establish an enhanced primary care payment amount – in addition to the base primary care capitated payment amount – as a feature of primary care capitated payment arrangements in the Shared Savings Program? If so, what should it look like?
d. If capitated payments are issued directly to ACOs, should CMS require ACOs to provide a specific percentage of those payments to ACO participants that provide primary care services? How might this be audited? Additionally, should CMS require ACOs to have written capitated payment agreements with ACO participants to specify that a minimum percentage of the capitated payment will flow to ACO participants?
e. For primary care capitated payment arrangements outside of the Shared Savings Program, what would be the appropriate services to bundle in such a primary care global period (e.g. E/M, care management codes, AWV)? How should the agency consider the benefits and drawbacks regarding quality of care, patient safety, and evidence regarding care delivery changes in a fully- or globally- capitated approach with no per-visit payment vs. a hybrid payment approach with reduced per-visit payment and per-member per-month payment?
f. For both a fully capitated and hybrid payment approach, CMS has in the past considered patient complexity (e.g. number of chronic conditions or hierarchical condition category level) in our alternative payment models for primary care. How should CMS approach defining these levels or stratum for payments in a fully capitated or hybrid payment model for primary care? How many levels should be considered?
g. In the absence of an encounter, is there another appropriate 'trigger' or initiation for a primary care global period? How long should it last? Is beneficiary receipt of an AWV in the previous 12 months sufficient?
h. What necessary reporting requirements and accountability should CMS require for clinicians receiving primary care capitated payments? For example, should there be explicit minimum visit requirements for a clinician to be eligible to receive primary care capitated payments for their Original Medicare patients? Should we require specific clinical outcomes-based reporting? If so, what clinical outcomes should we measure?
i. Broadly, to what extent and how should the approach Original Medicare takes to primary care payment differ between the Shared Savings Program and the broader program?
j. In so much as the agency considers a prospective primary care payment (PPCP) for primary care, to what extent should the initial preventive physical exam/AWV be the initiating visit for that global period??
In addition to the questions above, the committee will provide feedback on following topics included in the proposed rule that builds off previous recommendations from the National Academies:

1) The change of G2211 to MOD1 and MOD2 inside and outside an ACO setting

2) New codes for Health Coaching.

3) Increased payment for collaborative care model and behavioral health integration

4) Use of empiric data in the potentially misvalued codes process during this year's nominations