Senators Whitehouse, Cassidy propose bipartisan primary care payment reform, seek industry feedback

U.S. Sens. Sheldon Whitehouse and Bill Cassidy, M.D., want to reform how primary care providers get paid through Medicare, and they also want to hear from the healthcare industry about the best way to do it.

Whitehouse, a Democrat from Rhode Island, and Cassidy, a physician and Republican from Louisiana, introduced a bipartisan bill, the Pay PCPs Act (S. 4338), Wednesday to better support and improve pay for high-quality primary care providers. 

The legislation serves as a marker for future primary care legislation and is intended to solicit feedback on a number of important policy questions, the lawmakers said.

The Pay PCPs Act would task the Centers for Medicare & Medicaid Services (CMS) with establishing hybrid payments to reward primary care providers who provide the best care to their patients—care that reduces patients’ emergency visits, hospitalizations, excess specialist services and other big cost drivers, according to a press release. 

The bill would provide Medicare beneficiaries with reduced cost-sharing for certain primary care activities and service and would also create a new technical advisory committee to help CMS more accurately determine Fee Schedule rates.

The proposed legislation would encourage CMS to accelerate its existing efforts to support value-based primary care and improve the adequacy of pay for primary care providers in Medicare, according to the lawmakers.

Whitehouse and Cassidy also issued a request for information (PDF) for feedback on policy questions. Feedback can be submitted to [email protected] until July 15, 2024.

In the RFI, the lawmakers outline the legislative proposal by outlining that the Medicare Physician Fee Schedule currently is comprised of activities and services that are ill suited to support primary care.

"Primary care requires ongoing care coordination and relies upon routine activities that are under- or non-reimbursed in the Fee Schedule. This legislation encourages CMS to adopt 'hybrid payments' for primary care providers in the Fee Schedule, accelerating ongoing efforts in CMMI models," the lawmakers wrote in the RFI.

"Hybrid payments give primary care providers in Medicare steady, upfront, and value-based payments for under-reimbursed activities, while maintaining some traditional FFS payments for certain services. Hybrid payments allow primary care providers to innovate and more easily integrate diverse care activities to improve care quality and reduce costs," they wrote.

“Primary care is a critical part of the health care equation.  Overwhelming evidence shows that primary care both improves health outcomes for patients and drives down health costs.  There are many issues to address in primary care, and we look forward to receiving feedback on our legislation through the RFI to make a meaningful difference to health care success,” said Sen. Whitehouse and Dr. Cassidy in a joint statement.

The U.S. spends more on healthcare as a share of its GDP than peer countries, but U.S. life expectancy is below that of its peer nations—and falling.  

For decades, the U.S. has underinvested in primary care, spending only 5 to 7 cents of every healthcare dollar on primary care. Other high-income countries spend 13 cents per dollar.

The U.S. primary care system suffers from "chronic lack of adequate support," according to a 2023 scorecard report.

Three in 10 people report not having a usual source of primary care, and reports find the U.S. will face a shortage of between 17,000 and 45,000 primary care doctors over the next decade, the lawmakers laid out.

Primary care groups immediately cheered the legislation.

Susan Dentzer, president and CEO of America's Physician Groups, which represents about 360 organizations, said the plan proposed by the lawmakers for a hybrid form of Medicare payment would combine prospective, per-member-per-month payments with fee-for-service. 

“This approach will enable many smaller physician practices not only to survive the current headwinds facing primary care, but also to build the infrastructure that they will need to thrive in value-based models—the direction in which the nation's health care system must continue to move," Dentzer said in a statement. "We also applaud the move to reduce copayments from Medicare beneficiaries for vitally important care coordination services.  America's patients, doctors, and the nation as a whole would be better off with this overall approach, and we look forward to working with policy makers to embed it in law and see it flourish in practice.”

Many primary care providers strive to provide patient-centered, coordinated healthcare that is accountable for costs and quality, she noted. "We can't achieve this goal without a strong basis in advanced primary care, and outside of value-based payment models, the current structure of Medicare fee-for-service physician payment doesn't adequately support the model, and in fact, undermines it," Dentzer said.

“We’re heartened to see Senator Whitehouse and Senator Cassidy’s bipartisan commitment to improving seniors’ access to comprehensive primary care by proposing legislation that would offer hybrid payment (a mix of Fee-for-Service and prospective payment) to Medicare primary care practices," said Ann Greiner, president and CEO of the Primary Care Collaborative, in a statement issued Wednesday.