2026 Medicare Physician Fee Schedule — ‘We care about primary care’

Primary care and prevention are key drivers of the 2026 Medicare Physician Fee Schedule (MPFS) and will be for Medicare going forward, said Medicare Director Chris Klomp.

Klomp, Medicare Principal Deputy Director Alec Aramanda, and Policy Director Joe Albanese met with R. Shawn Martin, CEO of the American Academy of Family Physicians, to explain how the U.S. Centers for Medicare & Medicaid Services (CMS) aims to deal with physicians and patients starting next year. Their panel discussion was hosted by Primary Care for America, an advocacy collaboration devoted to comprehensive, continuous and coordinated primary care.

Make America Healthy Again

Primary care has a primary role in the effort to Make America Healthy Again (MAHA). Going after the root causes of lack of health is the guiding policy of Health and Human Services Secretary Robert F. Kennedy, Jr., said Klomp, who also is CMS deputy administrator.

“As a country, we've made it very easy to be unhealthy and rather difficult to be healthy,” Klomp said. “Much of that starts with chronic disease, which affects more than 60% of Americans; polychronic, 40%; diabetic, emergent diabetic 30%. And so we take seriously this challenge, and we know as payer, we have a bolus of resources that we can apply toward trying to make changes.”

Some primary care policy drives toward prevention. CMS spends tens of billions of dollars on quality measures, many of them process measures that are difficult to tie to improvements in health outcomes, Klomp said.

Measures that are thought of as preventive in nature at best center on early detection of things like breast cancer or colorectal cancer. Those are important, but they’re not moving upstream, Klomp said.

“So we're starting to ask questions — should we be making investments 25 years earlier as Medicare, before someone joins our program at 65?” Medicare covers beneficiaries for an average of 17.8 years, Klomp said, so “that's not a foregone conclusion, by the way, that we can't make real differences in their lives based on changes, including reversal of chronic disease.”

Data is becoming clear around health effects of social isolation and loneliness. For those aged 65 years and older, it corresponds to a 30% increase in mortality — the same as smoking 15 cigarettes a day or having obesity with a body mass index of 30 or more, Klomp said. Apart from human costs, Medicare could be spending $8 billion a year in direct medical costs.

“That's a problem. That's an epidemic. There's something that we can do about that,” Klomp said.

A new health factor

Churches and family are best positioned to make a difference in that condition, but so can physicians and other health care providers. A broader definition of primary care means could include the principal provider broadly that beneficiaries interact with most frequently, and then CMS could use incentivizes through quality metrics and other incentives to spend time and have the resources to address an underlying root issue that itself then catalyzes a triggering effect into other chronic disease, Klomp said.

At the convergence of primary care and the MAHA movement, the CMS leadership believe in the principle of subsidiarity, with decisions made at the most local level, Aramanda said. They also understand the importance of primary care integrating with family, communities and churches to treat physical, mental and spiritual health all together, he said.

What are the principles here?

Overall, the 2026 MPFS will implement the split conversion from the Medicare Access and CHIP Reauthorization Act (MACRA), which will be important for clinician choosing between participation in an advanced alternative payment model and staying in the MIPS program. Over time, it will be a compounding factor that will make it more important to consider options for participating in APM participation, and it will be part of the overall shift away from fee-for-service into a more value-based paradigm, Albanese said.

CMS leaders also are emphasizing accuracy in the MPFS, Aramanda said.

“In addition to payment accuracy, I’d simply emphasize you’ll see this as a recurring theme from us, and we try to focus on principles in order to guide rules, as opposed to starting with rules and backing into principles,” Klomp said. “What are the principles here? We care about primary care. We want to drive participation into alternative payment models, we want to drive participation into preventive care. And so you’ll see that as a recurring theme, not just in this rule but ongoing.”

Fair competition

With the MPFS, the Outpatient Prospective Payment System and other CMS initiatives, leadership wants to allow physicians and other clinicians to compete based on the value they deliver for their patients, and be as neutral as can be about where the service is delivered, Aramanda said. They want to account for the transformation of medical practices in recent decades and create a bulwark for physicians practicing in their communities, whether independently or in a facility setting, he said.

Klomp agreed, noting CMS was not making a commentary against health systems or employed practitioners. He and Aramanda said CMS does not want to put a “finger on the scale” that harms community practices.

Determining accuracy

Returning to accuracy in payment, Klomp said payment schedules historically have been largely survey-based. But physicians are busy running practices and treating patients, so across some specialties, a low number of responses — possibly a statistically insignificant sample size — may determine reimbursement for an entire specialty. There are other data sources available, such as in-market, time-based studies and cost studies.

“There's no reason then at this point that we can't incorporate those data sources into our methodologies to more accurately pay,” Klomp said. “It’s a budget neutral fee schedule. The goal is truth. The goal is rooting ourselves in data and evidence first, and then applying policy on top of that for trying to drive emphasis toward primary care or preventive care. Great, but let's first understand simply, where are the costs? How much time does it take to render a service? And that's really all that this policy is meant to do. I think it's a first step. I think there are other steps that we can take, but I think it's an important signaling mechanism.”

Technology for accuracy

Policies that govern fee schedules are part of accuracy, and so is how CMS adjudicates claims, Klomp said. CMS processes about $1.5 billion in claims a day for traditional Medicare on computers using 1970s era COBOL code. Those make it difficult to understand true costs and utilization patterns across regions, practices, specialties and more, he said.

CMS Administrator Mehmet Oz, MD, MBA, has publicly discussed CMS, a $1.7 trillion program, having nine technical engineers when the new administration began in January, Klomp said. There will be more technical expertise to improve management on the back end, he said.

Telehealth

When CMS granted some telehealth flexibilities during the COVID-19 pandemic, the big concern was that it will be abused and over-used. A mindset was to make people visit physicians in brick-and-mortar offices to control utilization, Klomp said.

But there has not been rampant abuse of telehealth, he said.

“The guiding principle is, we want to meet our beneficiaries where they are, and we want to serve them however they want and need to be served, and we want to make it easy for providers to maintain that relationship however they can best render care,” he said. “And we don't want the government to be in the business of telling providers how to deliver care and what medical decisions they should be making for their patients. That's not our role.”

With the federal government reopened, CMS is free to pay everything again and is putting reimbursement in motion, Klomp said.

Albanese noted part of Medicare’s telehealth policy will be governed by Congress, but the leadership want to facilitate new services and work through the fullest flexibilities that they can.

Will it help primary care?

Martin praised the provisions and signals the administration has included in the 2026 MPFS.

“I know I speak for all the primary care community and physicians and clinicians across the country: We're appreciative of the signals that you made in the fee schedule to better support primary care,” he said. “I think we look forward to building on that and working with you to create a usual source of care, a usual source of primary care, for all Americans.”