“the drumbeat of primary care physician exits continues, atop the relative silence of trainee interest in the field, as more than 30% of US adults now lack a usual source of care.
In January 2025, 3 advanced primary care management (APCM) codes were introduced to inject additional dollars into primary care (G0556-G0558). Reflecting 3 levels of medical and social complexity, these APCM codes pay a per-patient, per-month fee for advanced primary care services (eg, urgent access, care management, population health management) without requiring time-based documentation. For a low-income beneficiary with 2 or more chronic conditions, the monthly fee is $80 in a facility setting or $107 in nonfacility practices; for a similar beneficiary absent low income, $36 (facility) or $49 (nonfacility); and for a beneficiary with 1 or fewer chronic conditions, $12 (facility) or $15 (nonfacility).
In July 2025, the Centers for Medicare & Medicaid Services (CMS) proposed 3 new monthly add-on codes for patients with behavioral health conditions who are simultaneously receiving APCM services. Two of these codes (GPCM1 and GPCM2) would pay primary care physicians a monthly fee for treating patients with behavioral health conditions in collaboration with a psychiatric consultant. Based on the psychiatric collaborative care model, this method involves an initial patient assessment, consultant-approved treatment plan, patient monitoring, and weekly follow-up with the consultant. The first month’s fee is $91 in a facility setting or $145 in nonfacility practices, and the fee is $99 or $134, respectively, in subsequent months. The third code (GPCM3) pays for general behavioral health integration services without psychiatric consultation, at $41 (facility) or $53 (nonfacility) per month.
[..] if a patient receives both APCM and behavioral health management, these reimbursement changes could easily double or triple Medicare primary care payments for the patient, a meaningful amount of new practice revenue. [..]
The proposed codes, together with their APCM prerequisite, would pay substantially more than primary care add-on fees in prior CMS models (which ranged from $5-$28 per month).6 Moreover, given the clinical benefits of behavioral health integration for managing medical comorbidities,7 this financial incentive for behavioral health integration for patients receiving APCM services appears to be well targeted. If the revenue makes it to the front lines of primary care, helping to hire staff, ease administrative burdens, and retain physicians, it could be a boost to primary care unparalleled since the inception of the relative value unit–based fee schedule more than 35 years ago. However, the journey of federal dollars to the front lines of primary care is a perilous, uncertain one.
The first challenge is take-up. Historically, most new codes for prevention and coordination have been billed in less than 10% of eligible cases, leaving untapped tens to hundreds of thousands of dollars annually per full-time physician. Documentation burden, lack of capacity, and reluctance to expose patients to Medicare’s 20% coinsurance are likely culprits.
[..] To the extent that these codes are profitable, they could spur an industry that helps build practice capacity in exchange for a portion of the fees. Companies could hire and staff mental health specialists for practices, more than doubling the behavioral health integration fee into a collaborative care fee. Whether this means better care or simply an arbitrage opportunity bears monitoring.
Moreover, so long as primary care subsidies require patient coinsurance payments, clinicians may be reluctant to systematically use these codes. Larger organizations may overcome this reticence with billers on the back end, although that route perpetuates the uneven distribution of subsidies to better-resourced practices. CMS could consider classifying these codes as preventive services, nullifying cost-sharing.
Even if intended take-up is high, primary care may not easily find psychiatric consultants to work with. Approximately half of mental and behavioral health clinicians do not accept insurance, and the remaining clinicians also spend substantial time in private practice. As long as private psychiatric practice garners hundreds to thousands of dollars per hour, it could be difficult for primary care (or the aforementioned companies) to find psychiatrists and psychologists willing to accept Medicare reimbursement rates.
To budget for these new reimbursement codes, CMS proposes to reform long-standing inflated time assumptions within physician fees. Through a so-called efficiency adjustment derived from its Medicare Economic Index, the agency proposes a 2.5% fee cut across the fee schedule in 2026 while essentially exempting primary care and behavioral health services. Thus, the cut targets procedural, imaging, and other specialty services, setting up a redistribution that will lead to concerted opposition.
Altering physician fees will likely affect patient care across medicine because fee cuts may lead to reduced volume in some cases but increased volume in others, depending on what services and payers physicians could substitute to. Also, the new codes could be gamed by practices more adept at billing, making taxpayer dollars pay not for better care, but for coding intensity.
The fate of this proposed rule will determine whether CMS is able to modestly, but meaningfully, reorient its physician fee schedule toward primary care. The public comment period for this CMS proposed rule ends on September 12, 2025. In public comments to date, pushback against the broader fee cut is already evident.
If successful, these new reimbursement codes—paired with CMS Innovation Center programs to improve primary care, state policies to increase primary care spending, and perhaps adoption by private payers—could strengthen primary care in the US. However, forthcoming Medicaid cuts and continued corporatization of primary care could overwhelm these reimbursement changes and keep pushing physicians away from the field. Thus, these fee schedule investments are necessary, although likely not sufficient, to achieve the vision of primary care for everyone.”
Full editorial, Z Song, JAMA, 2025.9.8