NHC Comments on Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the[...]

NHC Comments on Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies

NHC Comments on Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies (PDF)

September 9, 2024

Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

RE: Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; etc.

Dear Administrator Brooks-LaSure:

The National Health Council (NHC) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; etc. (CY 2025 PFS proposed rule).

Created by and for patient organizations over 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, equitable, and sustainable health care. Made up of more than 170 national health-related organizations and businesses, the NHC's core membership includes the nation's leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses and organizations representing biopharmaceuticals, devices, diagnostics, generics, and payers.

Health Equity and Access

The NHC appreciates CMS' efforts to address health-related social needs and encourages the agency to prioritize policies that reduce disparities in health care access and outcomes. Achieving health equity is a fundamental goal that requires a multifaceted approach, focusing on both systemic changes and targeted interventions to ensure that all individuals, regardless of their background or location, have access to high-quality health care.1

The NHC acknowledges the proposed upward adjustment in the Health Equity Benchmark Adjustment (HEBA) as a positive step towards enhancing equity in the Medicare Shared Savings Program (MSSP). However, the exclusion of the Area Deprivation Index (ADI) may limit the effectiveness of these adjustments in fully addressing disparities. The ADI is a crucial metric for identifying underserved communities, and its inclusion could ensure more precise targeting of resources to areas most in need. Additionally, considering that the proposed HEBA falls below the current standards for Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) participants, we encourage CMS to consider additional measures to attract new providers to the MSSP. Strengthening incentives for ACOs to serve underserved beneficiaries is essential for advancing health equity and ensuring all Medicare beneficiaries have access to high-quality, patient-centered care. The NHC recommends that CMS evaluate the integration of the ADI into HEBA and explore further strategies to enhance the impact of these adjustments on current and future ACOs.

We applaud CMS for its initiatives aimed at addressing social drivers of health (SDOH), which play a crucial role in shaping health outcomes. By integrating services that address SDOH, such as Community Health Integration and Social Determinants of Health Risk Assessment, CMS is taking significant steps toward creating a health care system that recognizes and addresses the broader factors affecting health. These initiatives are vital for identifying and mitigating the non-medical barriers that many Medicare beneficiaries face, particularly those in underserved and rural areas.2

The NHC strongly supports the emphasis on reducing health care disparities. Disparities in health care access and outcomes are prevalent across various dimensions, including race, ethnicity, socioeconomic status, and geography.3,4 These disparities contribute to significant differences in health status and quality of life among Medicare beneficiaries. By prioritizing policies that focus on reducing these disparities, CMS is working towards a more equitable health care system where all beneficiaries have the opportunity to achieve optimal health.5

One critical aspect of advancing health equity is identifying and addressing the specific barriers to care that exist in underserved communities, including rural areas.6 These barriers can include a lack of health care providers, transportation challenges, limited access to technology, and economic constraints.7 The NHC urges CMS to develop and implement targeted strategies to overcome these barriers. This can involve expanding telehealth services, increasing funding for rural health care infrastructure, and providing incentives for health care providers to practice in underserved areas.

The NHC also encourages CMS to engage in continuous dialogue with stakeholders, including patient advocacy organizations, health care providers, and community-based organizations. Input from these groups is essential for understanding the unique needs and challenges faced by different populations. Collaborative efforts can lead to the development of innovative solutions and best practices that effectively address health disparities. The NHC is committed to working with CMS and other stakeholders to share insights and supports policies that promote health equity.

Moreover, the NHC highlights the importance of data collection and analysis in advancing health equity. In line with the recent revisions to OMB's Statistical Policy Directive No. 15, which enhances standards for collecting and presenting race and ethnicity data across federal agencies, CMS should ensure that its data collection efforts are inclusive and representative of all Medicare beneficiaries.8 Comprehensive and accurate data on health care access, utilization, outcomes, and SDOH (including Z- codes) across different populations is crucial for identifying disparities and measuring the impact of interventions. This data can inform policy decisions and help track progress towards health equity goals.

In addition, the NHC supports the incorporation of health equity measures into quality reporting programs. These measures, including the use of Z-codes, can provide valuable insights into how well health care providers are addressing disparities and promoting equitable care.9 By holding providers accountable for health equity outcomes, CMS can incentivize efforts to improve care for underserved populations and ensure that health equity remains a central focus of health care delivery.

MSSP and Risk-Based Adoption

The NHC supports CMS' proposal to offer multiple options for risk-based adoption within the MSSP, including higher-risk tracks for providers who voluntarily opt into them. To safeguard patient interests, it is essential that all MSSP tracks, including higher-risk models, maintain robust protections to ensure that individuals with complex health needs have equitable access to care. CMS should continue to rigorously monitor patient outcomes across all risk tracks, with particular attention to higher-risk models to prevent unintended limitations on necessary treatments for high-risk populations. Furthermore, active engagement with patient organizations is critical to ensure the MSSP continues to prioritize equitable access and patient-centered decision-making across all models.

Telehealth Services and Flexibilities

The NHC appreciates CMS' proposed continuation of telehealth flexibilities, including the permanent availability of certain services. Telehealth has become an essential component of health care delivery, particularly for chronic disease management, preventive care, and for individuals with limited mobility or living in remote areas.10 During the COVID-19 pandemic, telehealth provided a safe and effective way for patients to receive care without in-person visits, significantly expanding access for many Medicare beneficiaries.11 Maintaining these flexibilities is critical to preserving the gains in access to care that telehealth has enabled.

The NHC strongly supports the proposed measures to enhance telehealth access and equity. Telehealth has demonstrated substantial benefits in increasing access to care, improving health outcomes, and reducing health care costs.12 These benefits are particularly evident for patients with chronic conditions who require regular monitoring, as well as for preventive care services that help detect and manage health issues early.13 The NHC supports CMS' inclusion of services such as Preexposure Prophylaxis counseling for HIV, International Normalized Ratio monitoring, and caregiver training as permanent telehealth options. These services address crucial aspects of patient care and significantly benefit from the convenience and accessibility telehealth offers.

Additionally, the NHC supports CMS' inclusion of audio-only telehealth for opioid treatment program services, which is vital for beneficiaries receiving substance use disorder and opioid use disorder treatment, providing enhanced choice and convenience.

We also support policies allowing distant site providers to bill from practice locations other than their home addresses, when appropriate. This flexibility enables more comprehensive virtual care and supports patients and providers in delivering timely, effective care.

Ensuring broad access to telehealth services is essential, especially for patients in rural and underserved areas, where transportation challenges, long travel distances, and limited local health care services often create barriers to care.14 Telehealth mitigates these barriers by bringing health care services directly to patients' homes, ensuring they receive timely and appropriate care regardless of location.

The continuation of audio-only communication options remains essential.15 These options ensure that patients without access to video-enabled devices or high-speed internet can still benefit from telehealth services. This is crucial for bridging the digital divide and ensuring that telehealth remains accessible to all Medicare beneficiaries, irrespective of their technological capabilities or socioeconomic status.

The NHC supports CMS' ongoing reimbursement of telehealth services at the non- facility rate. Telehealth services should not be reimbursed differently than in-person care, as telehealth has proven to be an effective, accessible, and widely utilized modality for many Medicare beneficiaries. We recommend that the non-facility rate apply to all telehealth services delivered outside of traditional health care facilities.

Expanding the range of services available through telehealth is equally important. This expansion should include primary care, specialty care, mental health services, and chronic disease management.16 A broader array of telehealth services will maximize its positive impact for Medicare beneficiaries. CMS should also continue supporting and reimbursing audio-only telehealth visits, as they are critical for beneficiaries who may not have access to video-enabled devices or high-speed internet.

The NHC urges CMS to invest further in telehealth infrastructure and support health care providers in effectively implementing telehealth services.17 This investment includes offering training, integrating telehealth into practice workflows, and providing financial incentives to support telehealth adoption. Additionally, addressing regulatory and administrative barriers is necessary to ensure telehealth is seamlessly incorporated into the health care system.

Moreover, the NHC stresses the importance of ongoing evaluation and improvement of telehealth services.18 CMS should establish robust data collection and reporting mechanisms to monitor telehealth utilization, quality, and outcomes. Gathering feedback from both patients and providers will provide valuable insights into telehealth's effectiveness and help identify areas for improvement, ensuring that telehealth services continue to deliver high-quality care.

Permanently integrating telehealth into the health care system would provide ongoing benefits, including improved access to care, reduced health care costs, and enhanced patient satisfaction.19 Telehealth reduces the need for costly emergency room visits and hospitalizations by providing patients with convenient access to preventive care and early intervention services. Additionally, telehealth offers a more flexible, patient- centered approach to care, allowing patients to schedule appointments at times that are convenient for them and reducing the stress associated with travel to health care facilities.

Artificial Intelligence

The NHC acknowledges the growing role of artificial intelligence (AI) in enhancing health care delivery, particularly through AI-augmented products and services. As these technologies become increasingly integral to patient care, it is essential for CMS to develop clear and consistent guidelines for the payment and coverage of AI-enabled services. Currently, the lack of a uniform payment methodology for AI services across CMS creates barriers to patient access, as many AI-augmented services are considered "indirect practice expenses" rather than direct reimbursable costs.

In light of the rising number of AI-based products receiving authorization from the U.S. Food and Drug Administration, the NHC recommends that CMS establish a comprehensive and consistent framework for the reimbursement of AI services. This framework should ensure that AI technologies are integrated equitably into the health care system, enhancing patient-centered care without creating disparities. To address these issues, the NHC urges CMS to initiate a standalone Request for Information (RFI) to gather detailed input from stakeholders on developing a dedicated payment framework for AI-augmented health care services. This RFI should aim to establish clear guidelines and payment methodologies that ensure AI technologies are utilized effectively and equitably in patient care. The NHC emphasizes that the implementation of AI should not detract from the core values of patient-centered care. Instead, it should serve to enhance the quality, efficiency, and accessibility of health care services.

Establishing clear payment pathways and guidelines will not only facilitate the adoption of innovative AI technologies but also ensure that they are used appropriately and effectively, ultimately benefiting both patients and health care providers.

Enhanced Care Management

The NHC appreciates CMS' efforts to incentivize integrated, team-based primary care management through the proposed "advanced primary care management" (APCM) payment model. This model is a significant step forward in promoting comprehensive, patient-centered care that addresses the multifaceted needs of individuals with complex health conditions. By incentivizing primary care teams to work collaboratively, this model can improve care coordination, enhance patient outcomes, and reduce health care costs.

The NHC encourages CMS to ensure that the APCM model is adequately funded to achieve its intended goals. Adequate funding is crucial for the successful implementation and sustainability of the APCM model. Without sufficient financial support, health care providers may face challenges in adopting this model, which could limit its effectiveness and impact.

Additionally, the NHC urges CMS to identify and minimize barriers to the implementation of the APCM model. These barriers can include regulatory hurdles, administrative complexities, and resource constraints that may hinder adoption. CMS should work closely with stakeholders, including health care providers and patient advocacy organizations, to understand the challenges they face and develop strategies to address them. Providing clear guidance, technical assistance, and streamlined processes can help facilitate the adoption of this innovative care model.

The NHC also emphasizes the importance of continuous evaluation and improvement. CMS should establish mechanisms to monitor the implementation and impact of the APCM model. Collecting and analyzing data on outcomes, patient satisfaction, and cost-effectiveness will provide valuable insights into the success of this initiative and identify areas for refinement. This ongoing evaluation will ensure that the model remains responsive to the needs of patients and providers and continues to deliver high-quality, coordinated care.

Furthermore, the NHC encourages CMS to foster collaboration and knowledge-sharing among health care providers. Creating forums for providers to share best practices, experiences, and lessons learned can accelerate the adoption and improvement of this care model. Collaborative learning environments can help providers navigate challenges, innovate solutions, and optimize the delivery of patient-centered care.

Direct Supervision Flexibilities

The NHC supports CMS' proposal to extend the pandemic-era definition of direct supervision, which allows for a virtual presence via real-time, interactive audio-video technology. These flexibilities have been crucial in maintaining access to care and optimizing workforce utilization during the COVID-19 public health emergency, particularly in the context of constrained clinical workforces. Continuing these flexibilities, especially for lower-risk services, will support timely care delivery while ensuring that patient care quality is not compromised. The NHC recommends that CMS establish performance metrics and engage with stakeholders to monitor the impact of these changes on both care delivery and patient outcomes, ensuring that the approach remains patient-centered and effective.

Behavioral Health

Support for mental health and substance use disorder treatments is critical for the well- being of Medicare beneficiaries. The proposed enhancements to behavioral health services, including new billing codes and expanded access to digital mental health treatment devices, are important steps forward in improving the availability and quality of care.

Mental health and substance use disorders significantly impact the quality of life and overall health of Medicare beneficiaries, often coexisting with other chronic conditions such as diabetes, cardiovascular disease, and chronic pain. These comorbidities exacerbate the challenges in managing overall health. By introducing new billing codes and expanding access to digital mental health treatment devices, CMS is taking vital steps to address these prevalent issues. Addressing mental health needs can also lead to better management of co-occurring chronic conditions, ultimately improving outcomes and reducing overall health care costs for beneficiaries.20

The introduction of new billing codes is essential for accurately capturing the range of services provided in behavioral health care. These codes facilitate proper documentation and reimbursement, ensuring that health care providers are fairly compensated for the critical services they offer. Accurate billing and coding are foundational to the financial sustainability of behavioral health practices and help integrate these services more seamlessly into the broader health care system.

The expansion of access to digital mental health treatment devices represents a significant advancement in the delivery of behavioral health care. Digital tools provide convenient and effective support for individuals with mental health conditions, offering flexibility and accessibility that traditional in-person services may not.21 By recognizing and reimbursing these digital treatment options, CMS is promoting innovation in mental health care and ensuring that beneficiaries have access to a diverse array of therapeutic modalities.22

The NHC urges CMS to ensure that these services are accessible to all beneficiaries, regardless of their geographic location or socioeconomic status. Access to high-quality behavioral health care should not be limited by barriers such as transportation challenges, provider shortages, or financial constraints. The NHC encourages CMS to develop and implement strategies to overcome these barriers, such as expanding telehealth services, providing financial assistance or subsidies, and incentivizing providers to serve underserved areas.

It is also crucial that reimbursement rates for behavioral health services reflect the true costs of providing high-quality care. Underfunding these services can lead to reduced access, lower quality of care, and increased burden on providers.23 The NHC supports reimbursement rates that are commensurate with the complexity and intensity of behavioral health treatments, ensuring that providers can sustain their practices and continue to offer essential services to Medicare beneficiaries.

The NHC emphasizes the importance of continuous evaluation and improvement in the field of behavioral health. CMS should establish robust data collection and reporting mechanisms to monitor the effectiveness of the new billing codes and digital treatment devices. This data can provide insights into patient outcomes, provider experiences, and overall system performance, informing future policy decisions and ensuring that behavioral health services continue to evolve and improve.

Furthermore, the NHC encourages CMS to foster collaboration and knowledge-sharing among health care providers, patient advocacy organizations, and other stakeholders. Creating forums for sharing best practices, experiences, and innovations can accelerate the adoption of effective behavioral health interventions and improve the overall quality of care. Collaborative efforts can help address common challenges, develop innovative solutions, and enhance the delivery of patient-centered behavioral health services.

Caregiver Training

The introduction of virtual caregiver training services recognizes the vital role that caregivers play in supporting patients, particularly those with chronic conditions and those recovering from major health events. The NHC supports the inclusion of new HCPCS codes for caregiver training, as caregivers are an essential part of the health care system. They provide critical support to patients in managing their health conditions, adhering to treatment plans, and recovering from major health events. By formally recognizing and reimbursing caregiver training through new HCPCS codes, CMS is taking an important step toward acknowledging the significant contributions of caregivers and providing them with the necessary resources to effectively care for their loved ones.24

Virtual caregiver training services offer flexibility and accessibility that traditional in- person training sessions may not. Many caregivers juggle multiple responsibilities, including work and family obligations, making it difficult for them to attend in-person training sessions. Virtual training provides a convenient and accessible way for caregivers to acquire the skills and knowledge they need to support patients, regardless of their location or schedule constraints. This flexibility is especially crucial for caregivers in rural or underserved areas who may have limited access to training resources.25

The NHC encourages CMS to expand the scope of caregiver training services to include not only physical health care but also mental health support. Recognizing the mental strain that caregiving can impose, it is essential to provide caregivers with the tools to support both the physical and mental well-being of patients. Additionally, the NHC supports the establishment of feedback mechanisms for caregivers participating in training programs to continuously improve the content and delivery of these vital services.

The NHC encourages CMS to ensure that these training programs are comprehensive, evidence-based, and adequately funded to achieve their intended goals. High-quality training programs should be developed in collaboration with health care professionals, patient advocacy organizations, and caregivers themselves to ensure that they are relevant, practical, and effective. Incorporating input from these stakeholders can help create training programs that truly address the real-world challenges faced by caregivers and provide them with actionable strategies and tools.26

The NHC also urges CMS to consider expanding these services to meet the diverse needs of caregivers and patients. Caregivers often face a wide range of challenges depending on the specific health conditions of the patients they support and their own personal circumstances. Expanding caregiver training services to cover a broader array of topics and formats can help address these diverse needs. This might include specialized training for managing specific chronic conditions, mental health support, palliative care, and navigating the health care system.27 Additionally, providing training in multiple languages and culturally sensitive formats can ensure that all caregivers have access to the information and support they need.

Moreover, the NHC emphasizes the importance of continuous evaluation and improvement of caregiver training services. CMS should establish mechanisms to monitor the implementation and effectiveness of these training programs, gathering feedback from caregivers and tracking outcomes to identify areas for improvement. This ongoing evaluation will ensure that the training programs remain responsive to the evolving needs of caregivers and patients and continue to provide high-quality support.28

In addition to expanding and evaluating training programs, the NHC encourages CMS to provide financial and logistical support to caregivers who participate in these training sessions. Caregiving can be a significant financial burden, and offering stipends, grants, or other forms of financial assistance can help alleviate some of this strain.29 Additionally, providing resources such as respite care or transportation assistance can make it easier for caregivers to attend training sessions and fully benefit from the information and support provided.

Preventive Services

The expansion of preventive services, including hepatitis B vaccinations and colorectal cancer screenings, is a positive development for public health. The NHC supports CMS' efforts to increase access to preventive services, recognizing their critical role in early detection and management of diseases. Preventive care is a cornerstone of public health, helping to identify health issues before they become severe, reduce the prevalence of chronic diseases, and improve overall health outcomes for Medicare beneficiaries.30

Hepatitis B vaccinations and colorectal cancer screenings are vital components of a comprehensive preventive care strategy. By expanding access to these services, CMS is taking significant steps to protect individuals from serious health conditions that can be effectively managed or even prevented through early intervention. Hepatitis B vaccination helps prevent a potentially life-threatening liver infection, while colorectal cancer screening is essential for detecting cancer at an early, more treatable stage.

The NHC recommends that CMS continue to explore opportunities to expand preventive care coverage under Medicare. This includes considering additional preventive services that can benefit the Medicare population, such as vaccinations for other infectious diseases, screenings for other types of cancer, and preventive measures for chronic conditions such as diabetes and heart disease. Expanding the range of covered preventive services will ensure that beneficiaries have access to a comprehensive set of tools to maintain their health and well-being.

One key aspect of enhancing preventive care is ensuring equitable access to these services. The NHC urges CMS to address disparities in access to preventive care, particularly for underserved and marginalized populations.31 Socioeconomic factors, geographic location, and other barriers can prevent individuals from receiving necessary preventive services.32 CMS should develop targeted strategies to overcome these barriers, such as increasing outreach and education efforts, providing transportation assistance, and offering services in community-based settings.33

The NHC also emphasizes the importance of public awareness and education about the availability and benefits of preventive services. Many Medicare beneficiaries may be unaware of the preventive services covered under Medicare or the importance of these services for their health. CMS should invest in robust educational campaigns to inform beneficiaries about the preventive services available to them and encourage their utilization.34 These campaigns can help dispel myths and misconceptions about preventive care and motivate individuals to take proactive steps in managing their health.

Furthermore, the NHC highlights the need for continuous evaluation and improvement of preventive care programs. CMS should establish mechanisms to monitor the utilization, effectiveness, and outcomes of preventive services. Collecting and analyzing data on preventive care can provide insights into the program's impact, identify gaps in coverage, and inform future policy decisions. This ongoing evaluation will help ensure that preventive services are delivering the intended health benefits and reaching all eligible beneficiaries.

Collaboration with health care providers is also crucial for the success of preventive care initiatives. The NHC encourages CMS to work closely with providers to integrate preventive services into routine care and ensure that these services are delivered efficiently and effectively. Providing training and resources to health care providers can help them educate patients about the importance of preventive care and guide them in utilizing these services.

Services Addressing Health-Related Social Needs

The NHC appreciates CMS' focus on health-related social needs (HRSNs) and the request for information (RFI) on newly implemented services such as Community Health Integration, Principal Illness Navigation, and Social Determinants of Health Risk Assessment. These services are crucial for addressing the broader drivers of health that affect patient outcomes.35

The NHC appreciates CMS' efforts to enhance Principal Illness Navigation (PIN) services as a critical component of addressing HRSNs. PIN services offer an opportunity to improve care coordination and patient outcomes, particularly for Medicare beneficiaries with complex health conditions. To maximize the potential of PIN services, the NHC encourages CMS to address barriers to accessing these services, including awareness gaps, limited provider capacity, and reimbursement challenges. Additionally, by clearly identifying the scope of services covered by new PIN codes and promoting the increased use of Z-codes for social risk factors, CMS can better capture and address the diverse needs of Medicare beneficiaries. The NHC supports CMS in exploring these opportunities and implementing strategies that enhance the accessibility and utilization of PIN services.

The NHC supports the increased utilization of Z-codes to document social risk factors as part of the PIN services. Z-codes are vital for capturing non-medical factors that influence health outcomes, allowing for more comprehensive care planning and resource allocation. The NHC urges CMS to encourage the consistent use of Z-codes across all relevant claims and to provide training and resources to health care providers to ensure accurate and comprehensive documentation. This will help in identifying and addressing the social determinants that significantly impact Medicare beneficiaries' health.

The NHC appreciates CMS' recognition of the importance of these services in the overall health care landscape. Addressing health-related social needs is a vital step towards improving health outcomes and achieving health equity.36 By including services like Community Health Integration and Principal Illness Navigation in routine care, CMS can help ensure that patients receive comprehensive care that goes beyond traditional medical treatments.37

The NHC encourages CMS to actively seek and incorporate feedback from a wide range of stakeholders, including patient advocacy organizations, health care providers, community-based organizations, and patients themselves. This feedback is essential to ensure that the services are designed and implemented in a way that truly meets the needs of the diverse Medicare population. The experiences and insights from these stakeholders can provide valuable guidance on the most effective strategies for integrating these services into existing care frameworks.38

Furthermore, the NHC urges CMS to prioritize the identification and mitigation of barriers to access for Medicare beneficiaries. These barriers can include social, economic, and logistical challenges that prevent patients from fully utilizing these high- value services.39 For example, transportation issues, financial constraints, and lack of awareness about available services can all hinder access. CMS should develop targeted strategies to address these barriers, such as providing transportation assistance, ensuring services are affordable, and conducting outreach and education campaigns to inform beneficiaries about the available resources.40

The NHC also emphasizes the importance of continuous evaluation and improvement of these services. CMS should establish robust data collection and reporting mechanisms to monitor the effectiveness of the services in addressing health-related social needs.41 This data can be used to identify areas for improvement and to refine the services to better meet patient needs. Additionally, providing health care providers with the necessary tools and resources to collect and analyze this data will be crucial for the successful implementation and sustainability of these services.

Financial Sustainability and Program Integrity

The proposed PFS conversion factor of $32.36 for CY 2025, a decrease of $0.93 (2.80%) from the current CF, raises concerns about its impact on access to care for Medicare beneficiaries. The NHC urges CMS to carefully consider the broader implications of this reduction, particularly its effects on the sustainability of physician practices serving vulnerable populations, including rural communities and low-income patients. Further reductions in the conversion factor could exacerbate financial pressures on physician practices, potentially leading to reduced access to care, especially in underserved areas. The NHC recommends that CMS explore alternative mechanisms for achieving budget neutrality, such as targeted adjustments focused on specific inefficiencies or gradual implementation to allow practices time to adapt. The NHC encourages CMS to engage with health care providers and other stakeholders to better understand the impacts of conversion factor adjustments.42 Ongoing monitoring and evaluation are crucial to ensure that these changes do not inadvertently harm patient access or the overall health care system.

Additionally, the NHC recognizes the importance of CMS' efforts to address significant, anomalous, and highly suspect claims to protect the integrity of the Medicare program. These fraud prevention measures are critical to ensuring Medicare's sustainability and preserving resources for necessary care. However, without robust mechanisms in place, there could be unintended consequences on ACOs and their ability to comprehensively serve beneficiaries. The NHC recommends that CMS develop clear, objective standards for when suspect claims are identified and refunded. Current rules allow for subjectivity and inconsistent application, which can create operational challenges for ACOs and undermine their ability to provide comprehensive care. By refining these standards and maintaining patient protections, CMS can balance program integrity with ensuring that legitimate claims for necessary treatments are processed promptly and that Medicare beneficiaries continue to have access to high-quality, patient-centered care.

Practice Expense RVUs and New Specialties

Accurate valuation of practice expenses is crucial for integrating mental health services into the broader health care system.43 By ensuring fair reimbursement for Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), CMS supports the inclusion of these essential services as fundamental components of comprehensive patient care. Proper valuation helps prevent the selective treatment of healthier patients, as it ensures that providers are adequately compensated for the additional time and resources required to care for patients with more complex or severe conditions.

The NHC supports CMS' decision to include utilization data for MFTs and MHCs in calculating practice expense Relative Value Units (RVUs). Mental health services are often undervalued, leading to disparities in access.44 Accurate RVUs ensure that MFTs and MHCs receive appropriate reimbursement, covering essential overhead costs and sustaining their practices. This not only supports the financial viability of mental health practices but also promotes equitable access to care for all patients, regardless of the complexity of their conditions.

While using proxy values from similar specialties is a reasonable start, the NHC urges CMS to continuously refine these values based on real-world data. Regular adjustments will better reflect the true costs of providing mental health services and adapt to evolving practice models, including the increasing use of telehealth.

Engaging stakeholders in this process is essential. CMS should actively seek input from mental health professionals, associations, and organizations to ensure that RVUs are accurate and equitable. Transparency in the methodology for calculating these values will also foster trust and collaboration, ultimately leading to more precise and fair reimbursement rates.

Valuation of Specific Codes

The NHC supports CMS' adoption of RVU Update Committee (RUC)-recommended work RVUs for new CPT codes related to Chimeric Antigen Receptor T-cell (CAR-T) therapy services. Ensuring accurate valuation for CAR-T therapy is crucial not only for fairly compensating the complex and resource-intensive nature of these advanced treatments but also for maintaining patient access to these life-saving options. Proper reimbursement will encourage the availability of innovative treatments across various health care settings, benefiting patients who may otherwise have limited options.45

Accurate valuation is also important for establishing a consistent approach to emerging therapies, ensuring that the reimbursement system supports medical advancements while safeguarding patient access to high-quality care. The NHC urges CMS to continue engaging with stakeholders to refine valuation methodologies, ensuring that they reflect the evolving landscape of medical technology and the real-world costs associated with delivering these advanced therapies.

Conclusion

The NHC appreciates the opportunity to provide input on the CY 2025 PFS proposed rule. Please do not hesitate to contact Eric Gascho, Senior Vice President of Policy and Government Affairs, at [email protected] if you or your staff would like to discuss these comments in greater detail.

Sincerely,

Randall L. Rutta
Chief Executive Officer

¹ Artiga, S. and Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Retrieved from https://www.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care- the-role-of-social-determinants-in-promoting-health-and-health-equity/

² Hood, C., Gennuso, K., Swain, G., and Catlin, B. (2016). County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine, 50(2), 129-135.

³ Wiliams, D., Lawrence, J., and Davis, B. (2019). Racism and health: Evidence and needed research. Annual Review of Public Health, 40. 105-125.

⁴ Tsui, J., Hirsch, J., Bayer, F., Quinn, J., Cahill, J., Siscovick, D., and Lovasi, G. (2020). Patterns in geographic access to health care facilities across neighborhoods in the United States based on data from the national establishment time-series between 2000 and 2014. JAMA Network Open, 3(5), e205105.

⁵ Chin, M. (2021). Advancing health equity in patient safety: A reckoning, challenge, and opportunity. BMJ Quality & Safety, 30, 356-361.

⁶ Singh, G. and Siapush, M. (2014). Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. Journal of Urban Health, 91(2), 272-292.

⁷ Coombs, N., Campbell, D., and Caringi, J. (2022). A qualitative study of rural healthcare providers' views of social, cultural, and programmatic barriers to healthcare access. BMC Health Services Research, 22(1):438.

⁸ Office of Management and Budget, "Revisions to OMB's Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity," 89 Fed. Reg. 18530 (2024) (to be codified at 44 C.F.R. pts. 1, 2, and 3).

⁹ Durfey, S., Kind, A., Gutman, R., Monteiro, K., Buckingham, W., DuGoff, E., and Trivedi, A. Impact of risk adjustment for socioeconomic status on Medicare Advantage plan quality rankings. Health Affairs, 37(7), 1065- 1072.

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¹¹ Patel, S., Mehrotra, A., Huskamp, H., Uscher-Pines, L., Ganguli, I., and Barnett, M. (2021). Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US. JAMA Internal Medicine, 181(3), 388-391.

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¹⁴ Henning-Smith, C. and Kozhimannil, K. (2018). Rural-urban differences in Medicare quality outcomes and the impact of risk adjustment. Medical Care, 55(9), 823-829.

¹⁵ Uscher-Pines, L., Sousa, J., Jones, M., Whaley, C., Perrone, C., McCullough, C., and Ober, A. (2021). Telehealth use among safety-net organizations in California during the COVID-19 pandemic. JAMA, 325(11), 1106-1107.

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