The Honorable Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services Department of Health and Human Services
Attention: CMS-17 Mail Stop C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850
RE: CMS-1807-P: CY2025 Payment Policies under the Physician Fee Schedule
Dear Administrator Brooks-LaSure,
The Rosalynn Carter Institute for Caregivers (RCI) and The Carter Center Mental Health Program (CC-MHP) appreciate the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule, CY 2025 Payment Policies under the Physician Fee Schedule. RCI and CC-MHP work together to advance former First Lady Rosalynn Carter’s decades-long advocacy focused on caregiving and behavioral health. RCI works to promote the health, strength, and resilience of America’s 53 million family caregivers through cross-sector partnerships, research projects and strategic initiatives, evidence-based programs, and advocacy efforts. CC-MHP elevates mental health and substance use disorders as a global health priority, promoting policies and practices that improve prevention, early intervention, and treatment in the United States, and globally.
RCI and CC-MHP commend CMS for supporting the proposed rule to cover the cost of physician caregiver training and clarifying and expanding eligible activities including direct-care management training. While there is work to do to ensure that providers can use and leverage this nascent policy, it represents a significant, meaningful action to advance systemic changes for caregivers. Insufficient training, for both behavioral and functional supports, contributes to caregiver strain and can lead to adverse health outcomes for both the caregiver and care recipient.
Again, this year, we highlight that caregivers are or often become secondary patients due to their role and are at increased risk for adverse physical and emotional health outcomes. Covering caregiver training is an opportunity for the system to strengthen its recognition and support of the health status of caregivers. We again recommend that in addition to providing and connecting to relevant training, providers assess the health of caregivers and refer to appropriate services. Although a comprehensive evaluation of the policy is premature, establishing and collecting performance indicators as well as patient/caregiver demographic information could help to highlight facilitators of uptake, barriers to implementation and dissemination, and reasons why a caregiver cannot access training. This could ultimately build toward an understanding of effectiveness. We urge CMS to develop and transparently collect performance indicators and convene a learning community of health care providers, family caregivers, community services providers, and others in the ecosystem to understand, in real time, the experience of providers and caregivers, identify barriers, and advance solutions.
Caregiver training support is perhaps the most straightforward way to embed caregivers more meaningfully in broader care teams, potentially improving both caregiver and care recipient health outcomes. Across the country, several programs in a variety of health care settings are experimenting with ways to strengthen caregiver participation in care teams. These sites could provide another mechanism to understanding how this new policy is used, uptake, and barriers to implementation, and these sites could be key partners in the learning community referenced above.
Last year, we submitted comments on the proposed rule requesting that CMS consider covering caregiver training via telehealth methods, citing the importance of this option for families for whom access, time, and/or transportation is limited. We are pleased that CMS is proposing to provisionally add caregiver training services to the list of available telehealth services. However, we continue to support a permanent policy as this will not only help to address service and support gaps in rural communities, where primary and specialized health services are low and chronic conditions are more prevalent, but also help to build the evidence base on effectiveness. Evaluating the utilization, performance, and impact on different conditions and delivered across different mediums will be important in informing future caregiver regulations.
Caregivers, when possible, should be provided with a choice of individual or group training allowing consideration of privacy issues, language preferences, and learning style. We are pleased that CMS has clarified that this training may be covered in group or individual settings and believe that providing the caregiver with a choice on training format is a key element of self-directed/patient-centered care.
Types of practitioners/ caregivers should not be limited but rather broad and expansive given the well-documented role of allied health professionals, community health workers, and certified peer specialists (persons with lived experience of mental illness or substance use disorder) trained to provide guidance and support to persons with behavioral health challenges. Given the shortage of clinicians, especially in rural communities, expanding who can provide some of necessary care and psychosocial support; has been shown to improve access, availability and outcomes.
Finally, along with our colleagues across the healthcare system, we request that CMS support clarification and/or creation of caregiver training programs standards to ensure that training is high-quality, and evidence based. We also support ensuring that payment rates for caregiver training are sufficient to incentivize provider uptake and evaluate the effects of requiring patient co-payments.
Thank you for your attention to these comments. RCI and the CC-MHP would be pleased to collaborate with CMS to further explore the implementation of these recommendations, please reach out to our colleague Diana Felner (diana@rosalynncarter.org or diana.felner@cartercenter.org) to continue a dialogue.