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Statement of Task

The National Academies of Sciences, Engineering, and Medicine will develop a written response to a Request for Information (RFI) for the Pay PCPs Act of 2024 issued by Senators Bill Cassidy and Sheldon Whitehouse on payment-related primary care challenges. The committee will produce a report with recommendations in response to the following questions from the RFI.

This legislation encourages CMS to adopt “hybrid payments” for primary care providers in the Fee Schedule, accelerating ongoing efforts in CMMI models. Hybrid payments give primary care providers in Medicare steady, upfront, and value-based payments for under-reimbursed activities, while maintaining some traditional FFS payments for certain services. Hybrid payments allow primary care providers to innovate and more easily integrate diverse care activities to improve care quality and reduce costs.

• How can Congress ensure we are correctly identifying the primary care provider for each beneficiary and excluding providers who are not a beneficiary’s correct primary care provider or usual source of care?
• How should Congress think about beneficiaries who regularly switch primary care providers? What strategies should CMS use to minimize disruption and administrative burden for these providers?
• How should the legislation address beneficiaries who routinely see two or more providers who could each plausibly be the “primary” care provider? For instance, a beneficiary who routinely visits both a family medicine provider and an OBGYN.

• What factors should Congress be considering when setting risk adjustment criteria?
• Should beneficiaries on Medicare Advantage be considered as part of the calculation or should Congress limit the pool to FFS only?

The legislation proposes to allow the Secretary to define quality measures for hybrid payments and suggests four which may be pursued: (1) patient experience, (2) clinical quality measures, (3) service utilization, including measures of rates of emergency department visits and hospitalizations, and (4) efficiency in referrals, which may include measures of the comprehensiveness of services that the primary care provider furnishes.

• Are these quality measures appropriate? Which additional measures should Congress be considering?
• What strategies should Congress pursue to minimize reporting and administrative burden for primary care providers who participate in the hybrid model?

The legislation allows the Secretary to include four types of service in hybrid payments: (1) Care management services, (2) Communications such as emails, phone calls, and patient portals with patients and their caregivers, (3) Behavioral health integration services, and (4) Office-based evaluation and management visits, regardless of modality, for new and established patients.

• Is this list of services appropriate?
• Are there additional services which should be included?
• Will including these services in a hybrid payment negatively impact patient access to service or quality of care?

This legislation creates a new advisory committee—separate and distinct from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC)—within CMS to advise the Agency on new methods to more accurately determine physician fee schedule rates and correcting existing distortions which lead to under-reimbursement for high-value activities and services. The legislation also provides for the inclusion of primary care and family medicine providers to help provide the perspective of those stakeholders. Finally, the bill ensures that the new advisory committee develop new methods that help address health disparities, quality of care, and Medicare beneficiary access to services.

• Will the structure and makeup of the Advisory Committee meet the need outlined above?
• How else can CMS take a more active role in FFS payment rate setting?