CMS's proposed CY2027 payment rule rewards screening, weakens treatment accountability and opens new questions about AI and sensitive patient information. Here is what GHAI’s Overdose Prevention Initiative’s told Centers for Medicare and Medicaid Services.
A physician has ten minutes left with a 68-year-old patient. That is enough time to ask whether his drinking has changed or a pain prescription has become harder to manage. The question takes a minute. The answer can start months of treatment or go nowhere.
Every year, the Centers for Medicare and Medicaid Services (CMS) sets what Medicare pays clinicians in a rule called the Physician Fee Schedule. The 2027 proposal would make that minute more worthwhile. It would also stop requiring the provider networks that manage care for millions of people with Medicare to report whether patients with a substance use disorder ever begin treatment. GHAI's Overdose Prevention Initiative raised that contradiction in formal comments, which CMS must consider before finalizing the rule this fall.
CMS is also seeking input on using artificial intelligence (AI) in Medicare's annual wellness visit. GHAI urged it not to let AI flag patients for further assessment until the flags are proven accurate, correctable and protective of what patients disclose about substance use.
Paying for the question, dropping the follow-up
Medicare sets payment for each service partly by estimating how much of a clinician's time and skill it takes. CMS proposes raising that estimate by 19.1% for screening, brief intervention and referral to treatment: the short conversation in which a clinician asks about alcohol or drug use, talks through the answers and connects the patient to care when needed.
CMS would also change how that conversation counts inside accountable care organizations (ACOs), networks of doctors and hospitals Medicare pays to manage the care and costs of a group of patients. Medicare assigns patients to each ACO based on where they get primary care. Starting in 2027, the screening conversation would count as primary care in that decision. GHAI supports both changes.
Medicare grades ACOs on required quality measures and those grades help decide whether an ACO earns a share of the money it saves Medicare. In 2027, that list was due to include its first substance use disorder measure, tracking whether newly diagnosed patients start treatment and stay in it. CMS now proposes dropping it before ACOs report a single year of data. That would leave eight required measures, none with a substance use disorder focus. The screening conversation would help decide which patients an ACO is responsible for, while how well it connects those patients to treatment would have no effect on what it earns.
CMS says ACOs need less administrative activity while it moves quality reporting onto a digital system, a technical shift that lets software calculate results from patient records with no AI involvement. GHAI's response is practical: if ACOs need more time, delay the measure to a named year. Deleting it means Medicare never collects the data to tell whether these patients get treatment.
The timing is hard to miss. On September 15, the day after comments closed, CMS announced a substance use disorder track, starting April 1, 2027, in its ACCESS Model, a voluntary program that pays participating organizations based on whether patients' health measurably improves. CMS is building ways to measure and reward these outcomes in a pilot while removing the one measure that would have tracked them across ACOs.
Older adults are missing the decline
Overdose deaths fell for a third straight year in 2025, to a provisional estimate of 69,973, almost 14% below 2024. From 2023 to 2024, overdose death rates fell 37% among people 15 to 24 and only about 9%, among adults 65 and older, the smallest drop of any age group. Nearly 8,200 people 65 and older died of an overdose in 2024.
Medicare covers nearly all of them and its treatment gap is documented. Fewer than one in five Medicare enrollees with opioid use disorder receive medication to treat it, according to the HHS Office of Inspector General. A 2025 analysis of 2020 data found fewer than 40% of beneficiaries received care meeting national quality standards. The dropped measure would have shown whether those numbers change.
Payment policy can determine where treatment exists
Coverage helps only when a provider nearby can afford to accept it. Only about half of addiction treatment facilities accepted Medicare in 2024. In 2021, just 16% of U.S. counties had an opioid treatment program that did and rural residents can drive two to five times as far as urban residents to reach one.
Where those programs are scarce, doctors' offices fill the gap, yet Medicare pays them less than opioid treatment programs for comparable outpatient care. GHAI asked CMS to narrow that difference and create billing codes for outpatient withdrawal and medical care some clinicians already provide with no way to bill Medicare. We also asked CMS to let rural and community health centers bill separately for this care, add recovery support to proposed group visits and keep their telehealth flexibilities through 2027.
AI raises a question of trust
The AI tools CMS is considering could collect information before the wellness visit, summarize histories and flag patients for follow-up. A federal regulation known as 42 CFR Part 2 gives records from addiction treatment programs stronger confidentiality than most health records, because disclosure can cost people jobs, custody or standing in court. A routine wellness visit falls outside Part 2, yet an AI tool used there could collect or share exactly what Part 2 exists to protect.
GHAI asked CMS to extend Part 2-level protections to substance use information handled by Medicare-supported AI, keep that information out of AI training and judge these tools by whether screening, referral and treatment improve.
Screening depends on candor. A patient who suspects an honest answer will travel through an algorithm has every reason to give a different one.
What the final rule will show
Back in the exam room, the patient has answered. Medicare has proposed to pay for the question. The final rule will show whether it also backs the path to treatment, checks whether the patient arrives and protects what the patient said along the way.
For more information on GHAI comments and policy resources, visit our resources library.
