'The right direction'

Medicare beneficiaries with chronic conditions generate a set fee for each visit to the Center for Primary Care in Augusta, Ga. Yet that visit will generate numerous tasks—including making referrals to calling in prescriptions to answering questions over the telephone from the patient's spouse. None is reimbursed by the CMS.

“For every E&M visit we get reimbursed for, there are seven other items of work that we don't get reimbursed for,” said Dr Paul Fischer, founder of the Center for Primary Care. “The vast majority of our work gets done outside of the 15 minutes you spend in the exam room.”

For hundreds of thousands of primary-care physicians across the country like the 27 who practice at the seven sites run by the Center for Primary Care, the era of unreimbursed evaluation-and-management, or E&M, care may finally be coming to an end. Recognizing that care coordination may hold the key to keeping healthcare costs in check for an aging population, the CMS last week proposed reimbursing doctors starting in 2015 for patient care-management activities that don't involve face-to-face contact.

The 605-page proposed rule, which set an unspecified fee for initial consultations and another for ongoing management of chronically ill patients, will be open for comment until

Sept. 6 with its final release set for around Nov. 1.

Many of the nation's primary-care advocates, who have been demanding stepped-up reimbursement of their E&M activities, including paying for phone calls and other activities that take place outside the traditional clinical setting, say the proposed rule marks a major step in the right direction. By assigning a proper value to the cognitive and non face-to-face services provided by primary-care clinicians, it begins the process of detaching primary care from a fee-for-service system that rewards volume over value.

“Philosophically, we totally agree with it, and it's what we've been advocating for,” said Amy Gibson, chief operating officer for the Patient-Centered Primary Care Collaborative, a coalition of 1,000 healthcare stakeholders dedicated to disseminating research, advocating for reforms and convening experts to promote medical homes. “One of the barriers to practicing as a medical home has been the lack of payment for care coordination and helping patients and families navigate the healthcare system.”

“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.

Handley said Group Health has already been meeting those requirements for years. He said the organization has been conducting telephone patient visits for 20 years, using secured electronic messaging for 13 and has been electronically sharing health information for 10. “It's been transformational for our patients and clinicians,” he said.

However, Group Health's structure as an integrated health insurance and care-delivery system with salaried physicians allows it to operate differently from most physician practices across the country. Having physicians on salary allow the system to delink their activities from the patient visit and gives them time to engage in extensive use of telephone or “virtual” visits that open channels of doctor-patient communication.

Dr. Jeffrey Cain, president of the American Academy of Family Physicians, said his organization has been advocating for these changes for years and was pleased to see the CMS proposal.

“For primary care to effectively survive, two things have to happen: Change the way we're paid—and this proposal is part of that process—and change the way family doctors practice,” Cain said. “This isn't just us saying, 'Pay us more.' The care model has to evolve.”

Another challenge, though, will be finding the money to fund these new payments. While some may be concerned the money could come from lowering other physicians' fees, Cain said the medical home model—and organizations such as Group Health that use it—have proven that practicing this way lowers costs by reducing emergency room visits, hospitalizations and hospital readmissions. Cain said he believes these savings would cover the new care-management payments to primary-care doctors.

Gibson of the Patient-Centered Primary Care Collaborative pointed to a new report that found how the Blue Cross and Blue Shield of Michigan medical home program achieved savings of

$155 million over three years. She added that the CMS would just be catching up with what private insurers and some state Medicaid plans have been doing for the past few years.

Aetna spokeswoman Tammy Arnold said her company is now paying medical home practices between $2 and $3 per member a month to cover non face-to-face care-management tasks and said similar, customized arrangements have been made for its affiliated accountable care organizations. She added that Aetna also pays a contracted rate similar to office visits for virtual “e-visits” and telephone consults with patients.

Paul Mahoney, spokesman for Community Care of North Carolina, the medical home network for the state's 1.3 million Medicaid enrollees, said physicians receive between a $2.50 and $5 per-member, per-month fee for care-management and population-health tools.

“Most doctors would like to see it a lot higher,” Mahoney acknowledged. “But it does create some flexible resources.”

A Nebraska Medicaid medical home pilot is paying a per-member, per-month fee between $2 and $4 to cover administrative and care-management expenses. If certain standards are met, the program offers an additional 5% payment for certain fee-for-service and evaluation and management codes.

Gibson said private and state plans have shown the value in paying for care management and coordination.

“They know and believe this is something that will improve health outcomes and save money,” she said. “That's why they're investing in it.”

The CMS has until November to hone its proposal. There is still a lot of skepticism about whether bureaucrats in Baltimore will be able to get it right. “CMS lacks understanding of this issue,” Fischer said. “They understand this biopsy was taken or that broken bone was fixed. That's piecework. This is not piecework.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks