HHS Finalizes Physician Payment Rule to Enhance Person-Centered Care and Health Quality

The U.S. Department of Health and Human Services (HHS) has finalized new policies in the 2025 Medicare Physician Fee Schedule (PFS) to enhance primary care, expand access to preventive services, and support whole-person care, including behavioral and oral health. This initiative aligns with the Biden-Harris Administration’s commitment to affordable healthcare.

Key points include:

  • Strengthening primary and preventive care and improving behavioral health access.
  • Leveraging the Inflation Reduction Act to ensure equitable care.
  • Encouraging participation in the Medicare Shared Savings Program, particularly for rural and underserved areas.
  • A 2.93% reduction in payment rates resulted in a new conversion factor of $32.35 for 2025.

Advancing High-Quality, Accountable Care

CMS is solidifying primary care as an anchor for the future of the US healthcare system by completing new codes and payment for advanced primary care services such as availability of care during evenings, weekends, and holidays and personal patient-centered care that targets their medical as well as social needs. These updates build on experience from value-based care models, which define the architecture of accountable care within Medicare.

Whole-person care amalgamates physical health, behavioral health, oral health, and social determinants of health with the aim of improving the well-being of the patient, according to CMS deputy administrator for operations and affairs, Dr. Meena Seshamani. ‘This final rule enhances primary care teams and ACOs – helping improve care for Medicare beneficiaries.’

New policies include strategies for enhancing cardiovascular health based on the Million Hearts® model and changes in the Medicare Shared Savings Program to allow eligible ACOs to receive early savings for additional services and infrastructure, with modifications for promoting health in ACOs serving underrepresented populations.

CMS improves payment accuracy in relation to anomalies in billing practices as well. Moreover, six new MIPS Value Pathways are added to improve the quality of care in such niches as ophthalmology and dermatology.

Increasing Access to Behavioral Health, Oral Health, and Caregiver Training

CMS is working towards offering more extensive health solutions through policies on behavioral, oral, and caregiver health. For the first time, CMS is proposing payment codes for FDA-cleared digital mental health devices, suicide and overdose prevention planning, and improving behavioral health/primary care integration. OTPs now also offer support services such as social health assessment, patient navigation, and recovery services.

The rule now extends to dental services for patients who have end-stage renal disease and who are on dialysis, in addition to those receiving cancer treatment and transplants. Also, CMS is approving payments for virtual caregiver training services, as part of the caregiving support programs by the Biden Administration.

Expanding Preventive Services: Hepatitis B Vaccine, Cancer Screening, and PrEP

To boost preventive care, CMS is extending hepatitis B vaccine coverage for Medicare recipients, allowing access at pharmacies at no cost. Colorectal cancer screening access is also broadened, especially for rural and underserved communities. CMS now includes payment for HIV prevention via Pre-Exposure Prophylaxis (PrEP) under Medicare Part B.

Telehealth Flexibility Preservation

With temporary telehealth provisions set to expire at the end of 2024, CMS is preserving select flexibilities to allow virtual supervision by certain practitioners and virtual teaching for medical residents. Starting January 2025, many pre-COVID restrictions will resume, limiting telehealth to rural medical facilities except for behavioral health, which may continue at home.

Implementing the Inflation Reduction Act

CMS is building on the IRA’s prescription drug provisions that require drug makers to give back to Medicare when drug prices increase beyond inflation so that beneficiaries can sustainably afford the drugs they need.

 


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