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Medicare Advanced Primary Care Management Program
On December 20th, 2024, the Centers for Medicare & Medicaid Services (CMS) announced a 2.8% reduction in reimbursement rates for healthcare providers. This is the 5th year in a row where reimbursement has been decreased.
In the current U.S. healthcare Fee-for-Service (FFS) Medicare payment model, primary care practices are reimbursed primarily for face-to-face office visits, leaving many critical aspects of primary care uncompensated. Here’s a breakdown of the issue.
1. Reimbursed Services:
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Office Visits: Practices are paid for the time spent during in-person appointments with patients. These visits are coded and billed according to the complexity and duration of the visit. The rate of reimbursement has decreased almost 20% in the past 5 years.
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Procedures and Tests: If performed in-office, certain diagnostics or procedures are reimbursed.
2. Unreimbursed Services:
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Care Coordination:
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Primary care providers often spend significant time coordinating care with specialists, hospitals, and other healthcare professionals to ensure continuity of care for patients.
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Example: Referrals, medication reconciliation, or post-hospital discharge planning.
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No Reimbursement: These critical tasks are not compensated under FFS.
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Phone Calls and Portal Messages:
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Many patients seek guidance or follow-up care through phone consultations or secure messaging portals.
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While these interactions save patients time and reduce unnecessary office visits, practices are not reimbursed for staff/provider time while performing these interactions. Providers receive an average of 20–40 portal messages daily, outside of standard clinic visits. Over a week, this adds several hours of uncompensated work, as portal communications are not reimbursed.
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No Reimbursement: Providers and staff spend 3-4 hours per day on these tasks. Practices absorb the entire cost of provider and staff time for these interactions.
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On-Call Care:
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Providing 24/7 access to on-call providers ensures that patients have support outside of regular office hours, reducing the likelihood of ER visits.
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No Reimbursement: Practices receive no compensation and absorb the cost of maintaining this availability. On-call providers are required to remain available for emergencies or consults but are not reimbursed This expectation places a significant burden on providers, as they must adjust their personal and professional lives to maintain readiness without financial compensation and this exacerbates stress, fatigue, and burnout among medical professionals,
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Prior Authorizations:
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Providers must dedicate significant time and resources to obtaining prior authorizations for medications, imaging, or specialist referrals as required by insurers. This process is labor-intensive and delays patient care. Prior authorizations have risen by approximately 20% over the past three years. This includes an increase in requests, denials, and appeals related to these processes.
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No Reimbursement: The administrative burden falls entirely on the practice with no compensation received, further straining resources.
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The Impact on Primary Care Practices
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Financial Strain:
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With Medicare reimbursements for FFS decreasing (by almost 3% annually over the past five years), practices face growing financial pressures to sustain these unreimbursed services.
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Rising operational costs, inflation, and decreasing reimbursement rates exacerbate the problem.
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Undervalued Efforts:
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Tasks like care coordination, prior authorizations, chronic disease management, on-call coverage, and patient communication are essential to improving health outcomes but are undervalued in the Fee-For-Service model.
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Burnout Risk:
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Providers must balance growing administrative demands with delivering patient care, working many uncompensated hours each week, which can lead to burnout.
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The Role of Advanced Primary Care Management
To address these challenges, Medicare has developed a new program called Advanced Primary Care Management to help support primary care. This program allows primary care practices to submit a small monthly charge to help:
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Sustain critical but unreimbursed services like care coordination, phone consultations, on-call access, prior authorizations, and portal access.
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Ensure financial stability and continuity of care for patients.
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Focus on delivering high-quality, holistic care that goes beyond office visits.
This model aligns better with patient needs and supports primary care practices in a complex healthcare environment that is increasingly demanding more services with less reimbursement.
Medicare Advanced Primary Care Management Fee Agreement
Advanced Primary Care Management services give you a team of dedicated health professionals who can help you plan for better health and stay on track. Medicare has identified the care of all health conditions as an important goal. Conditions are new and ongoing medical problems that must be managed effectively in a partnership between the health care team and the patient to maintain the best possible health. Medicare covers Advanced Primary Care Management services provided by this practice per calendar month.
I understand these chronic care management services are subject to the usual Medicare deductible and coinsurance applied to provider services.
I understand that DTC Family Health will provide the following services:
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24/7 access to my care team, phone and online check-ins and/or communication via the patient portal between visits.
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Care management of all my medical conditions, assistance with setting and meeting health goals to manage my medical conditions, medication management, health education, including timely scheduling of all recommended preventive care services.
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Creation of a comprehensive plan of care for all health issues and disease prevention.
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Coordination of my care between specialists, testing centers, pharmacies, hospitals, urgent care facilities, and home and community-based providers of clinical services.
While receiving Advanced Primary Care Management services we ask that you:
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Let us know if you plan to see a health care provider outside of our practice so that we can share/obtain important health information with them.
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Inform us of any medication changes, including supplements, over-the-counter medications, or any other changes made to your health routine, like a new exercise or eating program.
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Unless it is a life-threatening emergency, please call us before you go to the Emergency Department.
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If you are admitted to the hospital, please call and let us know before you are discharged.
I also understand that I can revoke this agreement at any time (effective at the end of a calendar month) and can choose, instead, to receive these services from another health care professional after the calendar month in which I revoke this agreement. Medicare will only pay one provider or health care professional to furnish Advanced Primary Care Management services within a given calendar month.
I hereby indicate by signature on this agreement that DTC Family Health PLLC is designated as my primary care provider for purposes of providing MEDICARE ADVANCED PRIMARY CARE MANAGEMENT to me and billing for them.
This designation is effective as of the date below and remains in effect until revoked by me.
Patient or guardian signature:__________________________________ Date:_________________