The retrospective observational study published in Annals of Internal Medicine (Smith et al., 2026) examined more than 377 million outpatient visits in the Epic Cosmos database from January 2024 through September 2025. It documented steady but disappointing uptake of the new G2211 add-on code, reaching roughly 27% of Medicare evaluation and management visits by mid-2025—well short of CMS's early projection that more than one-third of encounters would qualify. With its enormous sample size, the study carries substantial statistical weight, yet as an observational analysis it cannot prove why uptake remains low; no conflicts of interest were declared by the University of Maryland, Robert Graham Center, and UCSF authors.

The original MedicalXpress coverage accurately reports these utilization figures and specialty differences—highest in endocrinology and internal medicine, lowest in dermatology—but stops short of connecting the data to larger, chronic patterns of primary care underinvestment that have persisted for two decades. What it missed is how G2211's tepid reception mirrors the failed promise of earlier CMS attempts (transitional care management codes in 2013, chronic care management codes in 2015) that also suffered from complex documentation, audit fears, and payments too modest to offset added workload. A 2023 Health Affairs analysis of CCM code uptake similarly found utilization below 20% in most primary care practices despite serving patients with multimorbidity, citing administrative burden and average reimbursement of only $40–$75 monthly as core barriers.

The Commonwealth Fund’s 2024 report on primary care spending further illuminates the structural problem: the United States devotes just 5–7% of total health care dollars to primary care, compared with 14–19% in peer nations with better chronic-disease outcomes. Medicare’s fee-for-service chassis still rewards volume and procedures far more than the cognitive labor of longitudinal relationship-building, care coordination, and addressing social drivers of health. For the 60% of Medicare beneficiaries managing two or more chronic conditions, this translates into shorter visits, higher referral rates, increased emergency department use, and ultimately higher total program costs.

Specialty variation noted in the Annals paper is not random. Cognitive-heavy fields see more opportunity to bill G2211, yet even these clinicians appear deterred—likely by the code’s requirement to document “medical necessity” for ongoing care and fear that routine use could trigger audits. The original coverage also underplayed regional and practice-size disparities; smaller independent primary care practices, already operating on thin margins, face steeper electronic health record and billing obstacles than large health systems.

These gaps matter. When primary care cannot be adequately supported, chronic conditions such as diabetes, heart failure, and COPD are managed more reactively than proactively. The result is a predictable cycle: clinician burnout, early retirement, and worsening access that disproportionately harms rural, low-income, and minority Medicare populations. CMS must now confront uncomfortable budget reality—either raise the G2211 payment meaningfully, simplify its criteria, or accelerate movement toward hybrid value-based models that reward outcomes rather than discrete encounters.

The slow uptake of G2211 is therefore not an isolated coding curiosity; it is a diagnostic signal that Medicare’s current architecture still treats complex, non-procedural care as an afterthought. Until that changes, millions of older Americans will continue to experience care that is technically covered yet practically unsupported.