One of the most significant announcements included in the 2025 Medicare Physician Fee Schedule final rule is the creation of an Advanced Primary Care Management (APCM) program. In this Q&A, Prevounce Founder and CEO Daniel Tashnek discusses APCM, including defining the concept, sharing why he believes CMS created the new program, how primary care providers should respond to the development of the program, and what he believes APCM reveals about CMS's future plans.
Q: What are Advanced Primary Care Management (APCM) Services?
Daniel Tashnek: Advanced Primary Care Management (APCM) services are a set of comprehensive, patient-centered care activities that can only be billed by primary care providers (PCP). APCM services focus on the concept of whole-person care within a patient population-wide model. APCM emphasizes sustained relationships between patients and their healthcare teams and involves activities that extend beyond traditional, visit-based care.
APCM services require PCPs to meet the following key requirements:
- Comprehensive patient assessments
- Development of a personalized care plan
- Ongoing care coordination
- Non-visit-based care (e.g., 24/7 care team access, remote communication)
- Use of interprofessional teams
- Use of health IT systems to track outcomes, facilitate communication between providers, and integrate care delivery
Q: Why do you think CMS created the APCM program?
DT: APCM is the latest of many initiatives from CMS demonstrating its desire to try and push practices that are heavily reliant on fee-for-service (FFS) structure into accepting population-based payment model elements. CMS has been piloting similar models over recent years through opt-in, alternative payment models like Primary Care First and Comprehensive Primary Care Plus (CPC+). I view APCM as an innovative model in that it allows CMS to introduce non-FFS elements into the traditional FFS program.
The current incarnation of APCM has no downside risk to primary care providers, providing a win-win entry point for FFS providers to explore and become more comfortable with more population-based structures. APCM is entirely voluntary for practices for now.
To elaborate further, CMS has been trying to push primary care more towards population-based models such as capitation and shared savings for many years with mixed success. While capitation and shared savings required major changes to practice workflows and priorities, APCM is a relatively low-lift add-on that can be performed while all other services remain FFS. Although this is not explicitly stated by CMS, I believe that all parties understand that APCM will increase costs in the short term but that CMS is willing to pay those costs in the hope that this investment increases the acceptance of more population-level payments that are tied to population outcomes to be released in the future
In addition to the general desire for population-level payments, CMS rightfully noted in the APCM announcement that primary care providers often spend a significant amount of time on activities like care coordination, patient education, and remote monitoring. This is work that typically goes unreimbursed in the current system when PCPs do not hit a specific time threshold that not all patients need. The APCM program is designed to address this concerning gap by compensating PCPs for the comprehensive and continuous care they offer to their patients — regardless of the exact time spent furnishing the services each month.
The APCM program reflects CMS's desire to encourage longer-term, patient-centered care relationships and to promote better chronic health outcomes, especially for patients with chronic conditions who require ongoing management. This program also aligns with CMS's broader goal of achieving cost-effective care by reducing hospitalizations and emergency department visits through better preventive and coordinated care.
Q: What need do APCM services fill?
DT: APCM services are meant to fill the need for population-level payments that support the full scope of work involved in managing a primary care office patient's health. Under traditional FFS models, primary care providers are reimbursed primarily for in-person visits or by achieving what I would argue are arbitrary care management time benchmarks. These benchmarks either limit PCPs' ability to fully engage with the patient or else causes providers to not get reimbursed for activities that improve long-term health outcomes but where a full 20 minutes of time spent, for example, was not warranted. Many critical services, like care coordination, chronic disease management, and patient education, often go uncompensated, despite being essential to maintaining the health of patients with complex needs.
APCM services are meant to address this by offering compensation for the wide range of activities required to deliver comprehensive care, particularly for patients with multiple chronic conditions, without regard for the amount of time each month the activities are furnished. This incentivizes primary care practices to make sure patients have access to these valuable services. This then better ensures that PCPs can focus on long-term health strategies without financial disincentives, which I believe will ultimately lead to better health outcomes and more sustainable care delivery.
Q: How does advanced primary care management differ from other care management programs?
DT: Advanced primary care management differs from other care management programs primarily in that it does not require any specific amount of time spent providing care management to the patient in order to be billed. In programs like chronic care management (CCM) or remote patient monitoring (RPM), providers are required to spend a minimum of 20 minutes per month delivering care management services to the patient before they can bill for those services. APCM, however, introduces a more flexible model that allows primary care providers to bill for services based on the availability of comprehensive care management to the patient, rather than the amount of time spent delivering those services.
This key difference shifts the focus from tracking and documenting time to ensuring that the infrastructure and services are in place to meet a patient's ongoing needs. As long as all required APCM service elements are available to the patient, PCPs can then bill for APCM without adhering to time-based thresholds.
This structure would seem to reflect CMS's effort to move away from rigid time-based billing requirements and toward a model that supports the delivery of comprehensive, proactive, and patient-centered care. It gives PCPs more flexibility in how they manage and deliver care, enabling them to focus on patient outcomes rather than tracking minutes spent on care management tasks.
Q: What are advanced primary care hybrid payments?
DT: While APCM is receiving the bulk of the attention from media, CMS's comments on future advanced primary care hybrid payments should not be overlooked. These hybrid payments would be a step-by-step continuation of APCM that would continue to pull services that have traditionally been FFS, such as office visits, into a population-level model. CMS requested comments on what other FFS services might be brought into a per-head APCM payment, which is further proof of CMS’ intention to use APCM as a conduit to population-based and value-based payments.
Q: Now that CMS has confirmed APCM is being implemented in 2025, how should primary care providers respond?
DT: Primary care providers should take steps to prepare for the new billing and care delivery model. A few steps I would recommend PCPs take are as follows:
- Review your current workflows. Providers should assess how they currently deliver care and identify areas where they can incorporate more non-visit-based services (e.g., care coordination, remote monitoring, patient follow-ups).
- Build interprofessional teams. Since APCM emphasizes team-based care, providers should build or expand their teams to include care coordinators, behavioral health professionals, and other specialists to meet the diverse needs of their patients.
- Invest in health IT systems. Primary care practices will need robust health information technology systems to track patient data, manage care plans, and ensure effective communication between care team members. PCPs should assess whether their current IT infrastructure is capable of checking these boxes.
- Train on APCM codes and hybrid payments. Providers should familiarize themselves with the new APCM billing codes and understand how the advanced primary care hybrid payment model will affect their revenue streams. Ensuring staff are trained on proper billing practices will be crucial to capturing all reimbursement owed for APCM services delivered.
- Improve patient engagement. Providers should develop strategies to enhance patient engagement in their care plans, particularly for patients with chronic conditions. Strategies may include engaging in regular communication with patients, delivering more patient education, and leveraging remote patient monitoring tools.
By taking these steps, PCPs should be able to optimize their practice to align with the new APCM requirements and benefit from the opportunities this payment model presents.
Q: What does CMS's plans around APCM tell us about their likely future intentions?
DT: CMS's plans around APCM appear to indicate a clear direction toward further promoting value-based care models and continuing to move away from volume-based, fee-for-service reimbursement. The focus on primary care providers delivering comprehensive, team-based, and continuous care reflects CMS's commitment to improving outcomes and reducing costs by encouraging proactive health management and long-term care relationships.
The development of Advanced Primary Care Management and advanced primary care hybrid payments also signals CMS's broader intention to expand payment models that reward providers for quality outcomes, preventive care, and care coordination. In the future, I expect CMS to continue developing and refining payment structures that hold providers accountable for patient health outcomes while reducing unnecessary healthcare utilization, like avoidable hospitalizations and emergency room visits.
APCM is likely just one more step in CMS's broader strategy to align provider incentives with the delivery of high-value, patient-centered care across the healthcare system.
Learn More About APCM In Our Upcoming Webinar
Prevounce will be hosting a webinar on Nov. 19, 2024, at 2 pm ET/11 am PT where we will further discuss APCM and the other significant remote care management changes and additions included in the 2025 physician fee schedule final rule. Register for the webinar today!