Medicare Is Asking the Public How to Pay for Primary Care by the Month. Comments Close September 14.

Legislation by DPC Insider
#medicare#cms#prospective-payment#capitation#primary-care#rulemaking
Sources: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule — Federal Register, July 16, 2026 · Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Rule — CMS Fact Sheet, July 14, 2026 · Public comment docket CMS-2026-2377, file code CMS-1848-P — Regulations.gov · How can primary care Make America Healthy Again? CMS wants to know — Medical Economics, August 3, 2026 · ACO Primary Care Flex Model — CMS Innovation Center · Implementing High-Quality Primary Care — National Academies of Sciences, Engineering, and Medicine, 2021 · 2026 State of Direct Primary Care Report — DPC Alliance · A Primary Care Panel Size of 2500 Is neither Accurate nor Reasonable — Journal of the American Board of Family Medicine, 2016

Roughly a hundred pages into the CY 2027 Medicare Physician Fee Schedule proposed rule, CMS stops proposing and starts asking. One of the questions: should Original Medicare pay for primary care as a bundled monthly amount covering a defined interval of care, the way it already pays for surgery and maternity care?

The section is called “Redesigning Primary Care To Make America Healthy Again.” It ran in the Federal Register on July 16. Comments close September 14, 2026. Medical Economics covered it again on August 3, quoting CMS’s Jake Quinton, MD, who described it as one of the more substantive requests for information in the rule.

What CMS put on the table

The agency asked for comment on three things: how to fix the relative undervaluation of primary care inside the current fee schedule, how AI and other technology should change what primary care work is worth, and how to establish prospective primary care payment in the Medicare Shared Savings Program and possibly across Original Medicare.

The framing is unusually direct for a federal rule. Fee-for-service, CMS writes, “has inherent limitations as a primary care payment mechanism, as it is not designed to support the comprehensive, coordinated care that primary care requires.”

There’s a sharper line a few pages earlier. Office and outpatient evaluation and management codes, the agency notes, “do not distinguish between a one-time consultative visit and care that is part of a longitudinal care relationship, which may require additional time, coordination, and resources.”

Any physician who left insurance-based practice recognizes that sentence. It’s the billing problem that made the exit worth considering in the first place, now printed in the Federal Register as an official concern.

The global period question

Here’s the part worth reading twice. CMS is floating a primary care “global period,” borrowing the structure Medicare already uses for surgical and maternity episodes.

From the rule: “Primary care, once an initiating visit has occurred, could also be reimbursed over an interval of care consistent with the development of a trusting, longitudinal relationship between clinician and patient.”

The agency says it hasn’t proposed one before partly because claims data makes it hard to tell where a primary care relationship starts and where it stops. So it asked for help. What services should be bundled into the period, the annual wellness visit and care management codes included? Full capitation with no per-visit payment, or a hybrid with reduced per-visit payment plus a monthly amount? How many complexity tiers? What triggers the period, and how long should it last?

Then this one: “should there be explicit minimum visit requirements for a clinician to be eligible to receive primary care capitated payments for their Original Medicare patients?”

That is a design document for a DPC practice, written as a list of open questions.

The phrase that never appears

Search the entire 700-page proposed rule for “direct primary care” and you get nothing. Same for “membership.” Same for “subscription.” Same for “concierge.”

The precedent CMS cites is entirely its own: the Comprehensive Primary Care initiative, Primary Care First, the advanced primary care management codes finalized for 2025, and ACO PC Flex, where participating ACOs get a monthly per-beneficiary payment that replaces fee-for-service for eligible primary care services and must spend at least 90 to 95 percent of it on care delivery. The rule also concedes that interest in PC Flex was strong but many eligible ACOs that inquired never actually applied, citing the application timeline.

Outside its own pilots, CMS leans mostly on the 2021 National Academies report Implementing High-Quality Primary Care, which recommended hybrid payment combining monthly and visit-based amounts. MedPAC, the independent congressional advisory commission, gets cited twice in the same passage for the same point, and there are references to academic work in Health Affairs, JAMA Internal Medicine, and elsewhere.

So the evidence base is a decade of pilots run inside Medicare, read alongside advisory bodies and academic literature. Absent from it: the DPC practices that skipped the pilots entirely, took monthly payment directly from patients and employers, and have been running the experiment in the open since before the first pilot launched.

What a DPC comment could actually say

CMS asked how to define the trigger for a period of care. DPC practices answer that with enrollment rather than an encounter, which is a cleaner solution than trying to infer a relationship from claims.

CMS asked about minimum visit requirements. DPC practices have fifteen years of evidence on what happens when payment stops depending on visit volume, including the parts that don’t flatter the model. Panels shrink. The DPC Alliance’s 2026 State of Direct Primary Care Report, a survey of 465 physicians, found that practices reporting full panels cluster between 400 and 700 patients. Observed panels in conventional primary care run closer to 1,200 to 1,900, which is itself well under the 2,500 figure the field repeats out of habit. The gap is still large either way, and it has real staffing and access implications a federal program would need to plan for.

CMS asked what outcomes to require from clinicians taking capitated payment. That question deserves a practitioner’s answer, not a consultant’s.

Filing is straightforward. The docket is CMS-2026-2377 on regulations.gov, file code CMS-1848-P, and comments must be received by September 14.

What This Means

Nothing here is a proposal yet. A request for information is Medicare thinking out loud, and plenty of RFIs go nowhere. But the agency wrote down, in a rule that also cut the non-qualifying conversion factor 1.68 percent to $32.84, that visit-based payment is a poor fit for primary care. That admission is now in the record.

If you’re a DPC physician, the useful move is a short comment describing what you actually do. Not advocacy for the model as a category, and not a request that Medicare adopt DPC. Just the operational specifics: how you define the start of a relationship, what your panel looks like, what happens to utilization when a visit costs the patient nothing extra, and where the model strains.

If you’re a resident weighing primary care, the signal matters more than the outcome. The payer that sets the reference price for American primary care spent a dozen pages asking how to pay for a relationship instead of a transaction. That’s the question the DPC model was built around, and Medicare is now asking it in public with a deadline attached.