The highly anticipated 2024 Medicare Physician Fee Schedule (PFS) was released earlier this month packed with changes that the Administration hopes will advance health equity and expand health service access to underserved populations. Some of the proposed rules emphasize certain Medicare programs like the Biden-Harris Administration’s Cancer Moonshot initiative and the largest accountable care organization (ACO) program, the Medicare Shared Savings Program (MSSP). Additionally, the new rule highlights primary care and contains provisions that align with HHS’ Initiative to Strengthen Primary Care.

The PFS is broken down by sections starting with updates to the proposed payment rates for clinicians. CMS proposed that rates should be reduced by 1.25% compared to 2023 while also increasing payment rates for primary care visits and other services. The CY 2024 conversation factor is $32.75 which is $1.14 or 3.34% less than CY 2023. The next set of proposed changes are for community health and caregiver support services to address unmet health related social needs. CMS would like to pay for certain caregiver training services so practitioners are paid to engage with caregivers to support Medicare beneficiaries. CMS is also proposing separate coding and payments for community health integration services such as person-centered planning and facilitating access to community-based resources that interfere with diagnosis and treatment. These services are the first of its kind to be included in the PFS that involve community health workers who connect underserved communities with social and health care services. Under the Cancer Moonshot initiative, the PFS introduces payments for (1) Principal Illness Navigation services that will help patients navigate cancer and other illness treatments and services and (2) certain dental services before and during various cancer treatments like chemotherapy. This rule also proposes coding and payment for social determinants of health risk assessments that can be added on to annual wellness visits or with an evaluation/management visit.

To support whole-person and primary care, the PFS proposes first-time services. CMS proposes to allow marriage and family therapists and mental health counselors (e.g., addiction counselors) to enroll in Medicare and bill for the first time. The rule also includes new payment rates and coding for crisis care, substance use disorder treatment, and psychotherapy. The rule also focuses on improving and extending telehealth services within Medicare. It proposes to add health and well-being coaching services temporarily to the Medicare Telehealth Services list and permanently to the Social Determinants of Health Risk Assessments. Other extended flexibilities include:

• expansion of the definition of eligible telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists;
• continued payment for telehealth services furnished by FQHCs and RHCs using the methodology established for those telehealth services during the PHE;
• delaying the requirement for an in-person visit with the physician or practitioner within 6 months prior to initiating mental health telehealth services, and again at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs and FQHCs; and
• continued coverage and payment of telehealth services included on the Medicare Telehealth Services List as of March 15, 2020) until December 31, 2024.

Lastly, the 2024 PFS rule consists of many changes for the MSSP to align with CMS’ value-based care and health equity strategy. The updates in the rule are expected to increase participation in the program up to 20%. These updates include changing the assignment methodology to better promote access to primary care services and changing the financial benchmark methodology to encourage better participation among ACOs serving complex populations. CMS is also proposing to increase the performance threshold in the Quality Payment Program from 75 to 82 points for the CY 2024 Merit-Based Incentive Payment System (MIPS) performance period/2026 MIPS payment year. This increase aligns with CMS’ goal to allow practices to receive a higher positive payment adjustment. In this rule, CMS is also trying to enhance care for individuals with diabetes in the MSSP. They propose extending the Medicare Diabetes Prevention Program (MDPP) Expanded Model’s emergency flexibilities for the next four years which will allow practitioners to offer virtual MDPP services through December 2027. And in order to better align quality measures across CMS, this rule proposes aligning the Quality Payment Program with the Universal Foundation which will eventually include measures to assess the quality along a person’s care journey — from infancy to adulthood to end of life care.

In response to the proposed 2024 PFS regulation, various medical associations also released their reactions to these rules. On behalf of ACOs, the National Association of ACOs (NAACOS) thanked CMS for addressing several issues they advocated for including fair benchmarking policies and improvements in quality reporting. One trade group, the American Medical Group Association (AMGA), recognized CMS’ proposed reimbursement changes for telehealth and commended them for treating telehealth care as equivalent to in-office care. The American Medical Association (AMA), on the other hand, is concerned about the 3.34% reduction in physician reimbursement rates for CY 2024 on top of the 2% reduction in 2023. “When adjusted for inflation, Medicare physician payment already has effectively declined 26% from 2001 to 2023 before additional inflation and these cuts are factored in. Physicians are one of the only providers without an automatic inflationary increase,” the AMA’s statement read. They go on to state that this steady decrease disproportionately affects rural physician practices and practices that treat low-income and marginalized communities. The chair of the American Society for Radiation Oncology (ASTRO) Board of Directors shared the same sentiment in their reaction letter stating that the organization is disappointed by the proposed 2% cut in radiation oncology reimbursement. That is why many organizations like the American College of Rheumatology (ACR) support the Strengthening Medicare for Patients and Providers Act (H.R. 2474), a bipartisan bill introduced in April 2023 that modifies certain adjustments to payment amounts under the Medicare physician fee schedule. This bill would replace the separate conversion factors for alternative payment model participants and physicians with a single conversion factor. It would update the conversion factor to be equal to the annual percentage increase in the Medicare Economic Index, beginning in 2024. In other words, this new bill would increase physician payment rates and keep them adjusted for inflation.