Primary Care Wins on Paper: The Fine Print in Medicare's 2027 Proposal
As proposed, CMS's 2027 Physician Fee Schedule would move money toward primary care and behavioral health. However, budget neutrality means every dollar added comes out of someone else's payment, and the comment record shows that trade-off is far from settled.
HFMA's recent explainer gives that trade-off one dissenting voice: an orthopedic society. The rest of its case comes largely from CMS's own Chief Medical Officer. The comment letters filed since July tell a broader story. The opposition reaches well beyond orthopedics, and it is not only specialists who have doubts.
Where CMS Has Broad Support
Primary Care and Behavioral Health groups have argued for years that their services are underpaid relative to procedures. The AAFP's 122-page comment letter welcomes CMS's recognition of that problem.
Several pieces have real support. G2211 is an add-on code that pays extra when a visit is part of ongoing care for a serious or complex condition. CMS would turn it into a modifier worth 16% of the visit's value, or 32% for clinicians in Shared Savings Program or LEAD Model ACOs. That should make it simpler to bill.
Behavioral health gains the most. HFMA reports that Collaborative Care Model services, which build behavioral health into primary care, would rise 20% to 40%. SBIRT (screening, brief intervention and referral to treatment) would rise roughly 20%. In CMS's own impact table, clinical social workers (+12%) and clinical psychologists (+11%) are the biggest winners.
The AHA backed the Shared Savings Program changes, including beneficiary cost-sharing reductions. Value-based care groups such as Accountable for Health support the two-tier G2211 structure. However, the premise is not universally accepted. Specialty groups challenge how CMS values their work.
The Modifier 25 Fight
The most contested offset targets Modifier 25. Physicians attach it to show that an office visit was significant and separately identifiable from a procedure done the same day. When the procedure carries a 0-, 10- or 90-day global period, CMS would pay the higher-valued service in full and cut the other by 50%.
The specialty stakes show up in CMS's impact table. From relative value changes alone, dermatology and otolaryngology fall 9% and orthopedic surgery 7%, before the conversion factor cut is applied. CMS attributes these mostly to this policy and the practice expense rewrite.
This is not CMS's first try. In 2019 it proposed a nearly identical 50% reduction as part of a broader overhaul of office visit payment, then dropped it after stakeholder pushback. CMS's fact sheet says it still believes it is likely paying twice for overlapping work. An AMA-led coalition counters that the agency assumes duplication without evidence and has not addressed the concerns that sank the 2019 version.
The sharpest objection is a logical one, raised by compliance experts at UTHealth. Modifier 25 can be billed only when the visit is already significant and separate from the procedure. The modifier itself attests that no duplication exists. A blanket cut presumes the opposite of what every properly billed claim certifies.
The practical stakes are access and practice survival. The Texas Medical Association warns that physicians who diagnose and treat in one visit may start splitting care across appointments. The Arizona Medical Association points to CMS examples where the cut would pay less than the direct cost of staff and supplies. MGMA, the AHA and the Alliance of Specialty Medicine all oppose it.
There is a fair counterpoint. Modifier 25 has long been an audit target because of routine, automatic use, so CMS's concern about overpayment is not invented. The question is whether a flat cut is the right tool, or whether code-by-code revaluation through the RUC, as the AMA coalition proposes, would be fairer. That alternative has its own credibility problem: the RUC, the AMA-convened committee that recommends code values to CMS, has long been criticized by primary care advocates as weighted toward specialists.
Agreed Problem, Contested Fix for Practice Expense
The second offset rewrites how indirect practice costs are spread across services. It phases out an index built on 2007 survey data. Here critics largely accept the diagnosis. The Society of Interventional Radiology agrees the current data are stale, but says the replacement has not been validated and should be withdrawn.
The AMA notes CMS gives no reason for excluding 10- and 90-day global codes, which would lose out in the reshuffle. The American College of Radiology also renewed its opposition to a blanket 2.5% efficiency adjustment. Radiology's position is mixed, though: diagnostic radiology is projected to gain modestly, while interventional practices warn of harm.
Even The Winners Have Reservations
The supposed beneficiaries are not uniformly cheering. The AAFP asks CMS to hold off on converting G2211 to a modifier until open issues are worked out. A Medical Economics analysis finds the 16% modifier mostly replaces today's add-on rather than adding money. The meaningful raise goes to practices in qualifying ACOs, leaving practices outside those models with roughly what they get now.
Then there is the conversion factor, the dollar multiplier applied to every service. Since 2026 the statute sets two of them. CMS proposes $32.84 for most physicians, down 1.68% from $33.40, and $33.17 for qualifying APM participants, down 1.19% from $33.57. The main driver is the expiration of a one-year 2.5% boost Congress provided for 2026.
In CMS's impact table, family practice and internal medicine gain only about 1% from the relative value changes. By MedMoneyGuide's calculation, that still nets out to a small decrease for an average non-APM practice once the expiring boost is counted. For many primary care physicians, 2027 looks less like a raise than a smaller cut.
What to Watch in the Final Rule
The final rule is due in November. Three signals will show how CMS weighed the comments:
Whether the Modifier 25 cut is finalized at 50%, scaled back to the 25% alternative CMS floated, or dropped as in 2019.
Whether the practice expense overhaul proceeds on its two-year schedule or is paused for more validation.
Whether the G2211 modifier lands as proposed, and whether the ACO-only higher tier widens to other settings.
The honest framing is not "primary care wins." It is that CMS is making a deliberate choice about which care Medicare values most, inside a fixed budget. Whether that choice holds up depends less on the merits of primary care than on whether the offsets can survive scrutiny.
Beth Papetti, MBA FHM
Principal & Chief Operating Officer
References
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American Academy of Family Physicians. (2026, September 11). Comment letter on the CY 2027 Medicare physician fee schedule proposed rule [Letter]. https://www.aafp.org/assets/image/upload/v1789152230/pdf_lt_cms_mpfsfy27_091126.pdf
American Academy of Otolaryngic Allergy. (2018). Brief update on the final CY 2019 physician fee schedule. https://www.aaoallergy.org/brief-update-on-the-final-cy-2019-physician-fee-schedule/
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