September 9, 2024
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1807-P
P.O. Box 8016
Baltimore, MD 21244-1850
RE: File Code CMS-1807-P; Medicare Program; CY 2025 Payment Policies under the Physician Fee Schedule and other Changes to Part B Payment and Coverage Policies
Dear Administrator Brooks-LaSure:
The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the Notice of Proposed Rulemaking regarding the Medicare Physician Fee Schedule for Calendar Year 2025. Nearly 3.8 million New York State residents[1]—almost 20% of the population—are enrolled in Medicare. CMS’s policies have a significant bearing on the health of New Yorkers.
NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. Our Primary Care program works to advance policies and programs that enhance primary care services and health equity in New York State; this work has provided us with in-depth knowledge of how high-quality primary care systems and programs can maximize health care access and delivery.
The experience of NYHealth, our grantees, and our partners is particularly relevant to three areas in the proposed regulations: the new Advanced Primary Care Management codes, telehealth regulatory flexibility extensions, and the Community Health Integration codes. We offer comments on each of these topics below.
1. Establish Coding and Payment for Advanced Primary Care Management Services
We applaud CMS for introducing coding and payments for Advanced Primary Care Management (APCM) services. Many of the chronic disease management and care coordination services that define primary care occur outside the traditional clinical encounter. As a result, they have been historically undervalued in the fee-for-service reimbursement model. These new APCM services—that pay clinicians per person per month for a range of services—would better compensate many of these activities (e.g., ongoing communication, care transitions) and encourage team-based care. By combining services such as care management and remote communication into a single set of codes, removing references to clinician time, reducing documentation requirements, and allowing multiple types of primary care practitioners to bill for these services, the proposed codes offer primary care providers greater flexibility and resources for care management. Moreover, these codes align with CMS’s broader, multi-year effort to move toward hybrid payments and accountable care.[2] Successful adoption of APCM service codes in the Medicare market could also influence the commercial and Medicaid markets, thereby strengthening primary care services nationwide. Together, these codes reflect a needed improvement in the current fee-for-service environment.
Over the longer term, we urge CMS to move primary care providers further away from fee-for-service reimbursements and consider ways to induce more holistic, transformative changes for primary care payment, including implementing a hybrid capitated payment model for primary care, aligned with the National Academies of Sciences, Engineering, and Medicine’s recommendations.[3]
2. Preserve Equitable Patient Access to Telehealth
The temporary policies and regulatory flexibilities that CMS and state governments used during the Public Health Emergency facilitated increases in telehealth during the pandemic. CMS’s removal of delivery restrictions and broadening of Medicare reimbursement policies allowed providers to offer patients a wide range of virtual health care services in a variety of settings. These flexibilities were critical to expand access for patients facing barriers to in-person care, extend providers’ reach in the face of shortages and strain, and meet unmet need for primary care and behavioral health services.
CMS’s proposed extensions and expansions of regulatory flexibility continue to facilitate telehealth use. They align with recommendations for New York State policymakers to expand equitable access to telehealth, as outlined in a recent NYHealth-supported report from Manatt Health.[4] These recommendations include extending telehealth coverage and reimbursement, covering audio-only services on par with audio-visual services, and supporting telehealth policies that benefit federally qualified health centers (FQHCs). Among others, we commend CMS’s proposed provisions to:
- Create an expansive definition for “interactive telecommunications system” that includes audio-only technologies when patients cannot or do not wish to use video. Our grantees have demonstrated that marginalized patient populations often rely on audio-only technologies. For instance, New York City Health + Hospitals, the country’s largest safety net hospital, found that patients who were above 65 years of age, Black, and Hispanic were more likely to use audio-only visits than video visits.[5] This regulatory flexibility will help ensure marginalized patients have the option to seek care remotely—thereby narrowing, rather than exacerbating, disparities in access. It also signals to providers and policymakers that audio-only is a common and acceptable form of telehealth delivery.
- Continue to allow FQHCs to initiate and deliver mental health services without first providing in-person care. FQHCs are critical safety net providers for marginalized patient populations, and telehealth has been instrumental in enhancing access to care for FQHC patients. A recent NYHealth-commissioned analysis shows that behavioral health is the most common use of telehealth, now accounting for two-thirds of all virtual care encounters.[6] Telehealth also expands the reach of safety net clinicians amid behavioral health workforce shortages.
- Continue to allow providers to work from home to deliver telehealth services and permit clinicians to bill using their enrolled practice site rather than their home address. This flexibility reduces administrative burdens and, as CMS acknowledges, protects provider safety and privacy in the event of a future public health emergency. These continued flexibilities are also an important tool for clinician retention. In New York, where health care facilities like hospitals and FQHCs are now required to have either the provider or the patient on-site at the facility to receive full Medicaid reimbursement for telehealth, we have observed the opposite effect. In response, numerous FQHCs in New York have reported resignations from behavioral health clinicians, who seek flexible virtual work options in settings like behavioral health and substance use disorder clinics that do not face similar restrictions.[7]
3. Continue—and Adapt—Implementation of the Community Health Integration Billing Code for Community Health Workers (CHWs)
Last year, we commended CMS for establishing a Medicare benefit that allows providers to bill for Community Health Integration (CHI) services provided by CHWs—a first for Medicare beneficiaries. CMS leveraged its role as the largest health care payer in the country to expand access to services provided by CHWs and drove innovation by other payers like Medicaid.
We appreciate CMS’s invitation to provide feedback on barriers to providing and billing for these CHI services. Despite the promise of this new code, largely, our grantees and partners who serve Medicare beneficiaries have reported that it has been used to a limited extent or not at all. Many hospital systems, FQHCs, and community-based organizations (CBOs) have deemed it too burdensome to adopt new workflows and IT infrastructure needed to bill for CHI, given the small proportion of Medicare beneficiaries in their patient panels. Even among health systems serving a substantial number of Medicare beneficiaries, they have cited these operational issues, as well as a scarcity of CHWs, as reasons for limited uptake. For instance, an Accountable Care Organization in rural upstate New York that serves 10,000 Medicare (non-Medicare Advantage) beneficiaries has made no CHI claims in 2024.
In light of these barriers and in order for CMS to realize the promise of the CHI code, CMS should consider partnering with State Medicaid agencies to design complementary CHW benefits. For example, CHI only reimburses for CHWs’ labor to make connections to services, while State Medicaid programs are starting to reimburse for the delivery of health-related social needs services (e.g., medically tailored meals). There may be more opportunities to coordinate with State Medicaid agencies on reimbursement. Medicare and Medicaid benefits should cover similar services, be set at competitive rates, and have similar and streamlined documentation requirements; this would create incentives for and reduce barriers to greater uptake. In New York, as in numerous other states, CMS can align the CHI benefit with Medicaid benefits and 1115 demonstration waivers. CMS should also marshal its resources to help providers and CBOs gain awareness about the new CHI services and build the IT capacity needed to adopt and bill using these codes. Funding for IT infrastructure-building would be particularly useful in enabling referrals and data-sharing between providers and their CBO contractors.
In addition to addressing these broad challenges, we encourage CMS to consider and address specific issues raised by our partners about the documentation burdens of the current CHI code. For instance, our partners have reported challenges with the current requirement that only the clinician initiating the visit can bill for CHI services. In team-based care settings, where CHWs are delivering CHI services and other clinicians like social workers are supervising them, this requirement results in administrative burdens and confusion. Another issue is that, in the initiating visit, clinicians are required to document a specific chronic condition that CHI services can help manage, but often these services help manage overall health and not a specific chronic condition. One NYHealth grantee, a major health care system with an institutional commitment to integrating CHWs, has largely not billed CHI services because of these burdens; these documentation issues likely cause an even greater barrier to small health care providers and CBOs. We encourage CMS to explore other, more flexible documentation methods for initiating CHI services, such as using existing health-related social need screenings.
While our New York partners have shared their documentation issues, many providers and CBOs across the country have also reported challenges with the CHI benefit itself. For instance, national colleagues like the Partnership to Align Social Care have recommended changes with respect to the 60-minute minimum threshold, initiating visit requirements, FQHC billing limitations, and other elements. We encourage CMS to consider these suggestions.
While CMS may consider adjusting elements of and requirements for the CHI code to support implementation and enhance service uptake, it should maintain the focus on CHWs. We, like CMS, recognize that there are other “auxiliary personnel” that can provide CHI services to better manage patients’ health. However, CHWs are uniquely positioned to build trusting relationships with patients, and this code was pioneering because it supported CHWs through Medicare reimbursement. In New York State, the health care and CBO communities view the CHI code as one of several new sources of CHW reimbursement that can be leveraged to support integrating CHWs in health care. We urge CMS to avoid redirecting resources that are crucial for sustaining the CHW workforce and to maintain the flexible training and/or certification requirements that are appropriate for, and desired by, the community-based professionals in each state.
Thank you for the opportunity to provide comments on these proposed enhancements to the CMS 2025 Physician Fee Schedule. If you have any additional questions regarding the APCM codes, please reach out to Nicky Tettamanti, Program Officer. For additional questions related to telehealth or Community Health Integration, please contact Ali Foti, Program Officer.
Sincerely,
David Sandman, Ph.D.
President & CEO
New York Health Foundation
[1] Centers for Medicare & Medicaid Services. (2024, April). Medicare monthly enrollment. https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-monthly-enrollment.
[2] U.S. Department of Health and Human Services. (2023, November). HHS is taking action to strengthen primary care. https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf.
[3] National Academies of Sciences, Engineering, and Medicine. (2021). Implementing high-quality primary care: Rebuilding the foundation of health care. The National Academies Press. https://nap.nationalacademies.org/catalog/25983/implementing-high-quality-primary-care-rebuilding-the-foundation-of-health.
[4] Smith, J., Savuto, M., & Augenstein, J. (2024, July). Advancing telehealth access and utilization in New York State. Manatt Health. https://nyhealthfoundation.org/resource/ensuring-long-term-equitable-access-to-telehealth-in-new-york-state-opportunities-and-challenges/.
[5] Chen, K., Zhang, C., Gurley, A., Akkem, S., & Jackson, H. (2023). Patient characteristics associated with telehealth scheduling and completion in primary care at a large, urban public healthcare system. Journal of Urban Health, 100(3), 468–477. https://doi.org/10.1007/s11524-023-00744-9.
[6] Smith, J., Savuto, M., & Augenstein, J. (2024, July). Advancing telehealth access and utilization in New York State. Manatt Health. https://nyhealthfoundation.org/wp-content/uploads/2024/07/NYHealth_Manatt_Telehealth_Access.pdf.
[7] Ibid.
