The nonprofit Primary Care Collaborative (PCC) has published a report that incudes seven specific recommendations for policymakers to strengthen and sustain primary care in rural settings
“Closing the Distance in Rural Primary Care,” created in partnership with the Robert Graham Center, provides a snapshot of the state of rural primary care that includes a literature review, a description of federal legislative trends affecting rural primary care, a quantitative analysis of primary care trends and five case studies. The report concludes with seven policy recommendations that PCC says are aligned with action steps recommended by the National Academies of Sciences, Engineering, and Medicine in the 2021 report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.”
In a separate story, Healthcare Innovation highlights some of the comments made about the report by rural health stakeholders in a Nov. 12 webinar.
Among the policy suggestions are to transition primary care payment to a hybrid model and support rural health clinics (RHCs), FQHCs and other rural primary care participation in alternative payment models and ACOs. The report cites the 2021 NASEM report, which found that hybrid payment that includes both patient-based prospective payment and FFS would better support team-based, comprehensive services and population health management than FFS payment alone.
“Fortunately, CMS has begun taking steps to bolster chronic care management in Medicare with bundled monthly fees for ongoing chronic care outside of visits,” the report says. “Beginning in 2025, both RHCs and FQHCs and all PCCs who participate in Medicare are eligible to bill Medicare under new Advanced Primary Care Management (APCM) codes.”
The report explains that APCM codes are intended to support care coordination activities, are not time-based and can be billed monthly. CMS will expand the codes further in 2026 to include behavioral health integration to reduce the administrative complexity of billing for and providing behavioral health integration services. With continued investment and refinement, APCM codes could serve as a foundation for a more robust hybrid primary care payment model in traditional Medicare, the report says.
The case studies included in the report suggest APMs currently do not accommodate the realities of rural primary care practices. “Some Medicare ACOs support rural primary care participation in APMs, such as shared savings models, by aggregating beneficiaries and lowering financial risk while providing tools, data, and shared services for population health management and quality reporting,” PCC says. “In 2024, the CMS Innovation Center launched the voluntary Primary Care Flex model within the largest Medicare ACO program, with features intended to address barriers that RHCs, FQHCs and other small rural practices face. It is too soon to determine whether this new model will attract more rural primary care participation in ACOs.”
Here is a brief summary of the six other recommendations:
• Measure and report primary care spending; avoid reducing Medicaid reimbursement to primary care. The report notes that measuring primary care spending across payers and across rural and urban geographies provides important feedback about whether decision-makers are investing. The report adds that as states grapple with fewer federal Medicaid resources over the next several years due to H.R. 1, any reductions they make in primary care reimbursement will likely exacerbate the burden of chronic disease and behavioral health conditions in rural communities.
• Increase federal support for FQHCs and RHCs in rural communities. Congress should increase support for two proven primary care models that together serve almost all rural counties, PCC says that FQHCs and RHCs. Rural communities need more access points for the whole-person care these models can deliver when well resourced with interdisciplinary teams.
• Increase federal support for rural primary care workforce education and training in rural training sites. Congress should continue to fund Title VII and Title VIII of the Public Health Service Act at levels that, at minimum, keep pace with inflation. These programs support education of the broad interdisciplinary teams needed for whole-person rural primary care,
• Put primary care at the center of the $50 billion Rural Health Transformation Program included in the 2025 H.R. 1 legislation.
• Ensure that programs and resources intended to support rural health and primary care reach rural communities. The report explains that some federal programs and funding intended for rural health are being diverted to providers that do not primarily serve rural populations. Dual classification allows hospitals to qualify for more Medicare-funded GME slots and related funding, and to qualify for the 340B Drug Pricing Program by meeting a lower threshold designated for rural hospitals.
• Ensure workforce and payment policies strengthen rural community assets. Policymakers should promote data-driven site-neutral policies and avoid costly mandates and administrative burdens that fall disproportionately on independent practices, the report says.
