“I think primary care has been both under distress as a specialty and has been struggling to achieve its potential as a result of a fee-for-service structure that rewards volume,” agreed Dr. David Shute, medical director for GreenField Health in Portland, Ore. “I think what CMS is trying to do is absolutely the right direction: to pay for the important work that has everything to do with getting the right outcomes—both medical and financial.”
But many primary-care physicians are like Fischer, who remains skeptical because of the lack of details in the proposal. “There were no ideas with price tags attached to it, which shows how serious they are about it,” he said of the CMS proposal. “How many hundreds of procedures have they identified and figured out what the reimbursement should be? But yet there are still no concrete numbers for the way cognitive services are paid for.”
In making its announcement, the CMS expressed the hope that the new reimbursement codes would reduce overall healthcare costs. “We believe that successful efforts to improve chronic-care management for these patients could improve the quality of care while simultaneously decreasing costs (for example, through reductions in hospitalizations, use of post-acute care services, and emergency department visits),” according to the CMS.
The agency noted that providing care management to Medicare beneficiaries with two or more chronic conditions “requires complex and multidisciplinary care modalities” and the resources needed to do this “are not adequately reflected” in existing evaluation and management codes. Because of this, practices are not reimbursed for much of the work they do.
According to the CMS, this work includes “regular physician development and/or revision of care plans; subsequent reports of patient status; review of laboratory and other studies; communication with other health professionals not employed in the same practice who are involved in the patient's care; integration of new information into the care plan; and/or adjustment of medical therapy.” The agency also hopes the proposal will boost adoption of patient-centered medical homes.
Primary-care advocates have been fighting for years to get beefed-up reimbursement for physician E&M activities. Each step of the way, they have had to fight representatives from the medical specialty societies, which dominate the agenda-setting American Medical Association Specialty Society Relative Value Scale Update Committee, known as the RUC.
In October 2011, the CMS' advisory body recommended paying for care-coordination services such as telephone time, anticoagulant management to prevent strokes and group patient education sessions. But it proposed a complex plan that would have put a huge administrative burden on primary-care doctors, many of whom work in small or mid-sized practices.
For instance, the RUC suggested establishing three new codes for telephone time with patients: one for five- to 10-minute calls, another for 11- to 20-minute calls and another for 21- to 30-minute calls. That proposal drew scorn from primary-care advocates. “There needs to be a collective reimbursement for these activities because doing it per telephone minute, or per form, it's just not going to work,” Fischer said. “It would just grind everything to a halt if you send in seven different bills.”
The CMS must have heard the criticism. In its latest proposal, it came up with only two codes for patients with “complex chronic conditions expected to last at least 12 months, or until the death of the patient.” The first code would cover initial services of one or more hours for the initial 90 days of treatment. The second would cover “subsequent” services after that initial period.
It gets more complicated after that, but general requirements proposed by the CMS include linking care-management services to an annual wellness visit and obtaining patients' consent documenting their desire to receive these services.
“It's a step in the right direction,” said Dr. Matt Handley, a family medicine physician and medical director for quality at the Group Health Cooperative in Seattle. “The devil will be in the details and, if the burden of documentation is so high, people may choose not to spend their time doing it.”
Among the details under consideration by the CMS are requiring practices to use a certified electronic health-record system that supports access to care, care coordination, care management and communications. It would also require practices to demonstrate a systematic approach to electronically communicating and exchanging clinical information with other clinicians providing ongoing care to the Medicare beneficiary whose care the practice is managing.