Reform Update: Docs welcome Medicare pay for care coordination, but worry about administrative burdens

Primary-care physicians are embracing Medicare's move to compensate them for care coordination services they provide when patients aren't in their offices, although the CMS declined to eliminate the administrative burden that troubled many providers when the idea was proposed.

Many of the Patient Protection and Affordable Care Act's reforms rely on a strong primary-care foundation. To give providers a boost, the law contains such provisions as primary-care physicians getting paid at Medicare rates for Medicaid services in 2013 and 2014.

The new Medicare physician-fee schedule (PDF) reinforces this commitment to primary care by adopting a proposal to start reimbursing doctors in 2015 for non-face-to-face care coordination for Medicare patients with multiple chronic conditions.

“Elderly and disabled patients have complex, multiple and chronic health conditions that require the whole-person medical attention available only through primary-care physicians,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians. “Placing appropriate value on the primary-care services these patients require and establishing codes for chronic-care management are important steps in meeting their needs.”

While physicians in general were supportive of the idea, they expressed concern that the initial proposal for these evaluation and management services carried with it a high administrative and documentation burden.

The fee schedule includes more than 40 pages of discussion responding to some of these concerns.

Among the list of responses from the CMS was removal of the word “complex” from the regulations. Instead, when determining which patients with multiple chronic conditions would receive care complicated enough to be eligible for this new payment, the CMS will now just use the term “chronic-care management” to describe the services that will be reimbursed.

“We regret any confusion generated by our proposed use of the term 'complex' to describe the chronic-care management services that are not adequately reflected in the existing E/M codes,” the CMS stated in the fee schedule document. “Although the provision of these services is complex relative to the care management reflected in the existing E/M codes, we understand the confusion on the part of commenters regarding the number of patients within a practice that are potentially eligible for the service versus those that would be considered 'complex.' ”

The document also made note of comments the CMS received on its proposal to require a clinician be available 24 hours a day, seven days a week to respond to the needs of these patients. The CMS acknowledged that some felt this was impractical, but said it was moving ahead with that requirement.

“The evolving medical literature on chronic-care management and patient-centered medical homes emphasizes the central importance of members of the care team being available 24/7 to address a patient's acute chronic-care needs,” the CMS stated. “Moreover, we believe the 24/7 availability of the care team is an important factor contributing to higher resource costs for these services that are not currently reflected in E/M services. Therefore, we disagree with commenters who requested that we relax or phase in the 24/7 requirement.”

The CMS defined chronic-care management of patients with multiple chronic conditions as the “systematic assessment of patient's medical, functional and psycho-social needs; system-based approaches to ensure timely receipt of all recommended preventive-care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.”

Included in this is a requirement to develop a “patient-centered plan of care” document, which would typically include a “problem list,” expected outcomes, measurable treatment goals, symptom and medication management, and coordination of services delivered by specialists and social service providers.

Still in play are the standards the CMS will require for practices to prove they have the necessary infrastructure to provide high-quality, comprehensive and safe chronic-care management. It was noted in the fee schedule document that these standards would be developed in 2014 for implementation in 2015 and will go through “notice and comment rulemaking.”

“Treating patients with multiple chronic conditions requires significant work beyond the four corners of the physician's office,” the American Medical Group Association said in a statement. “We look forward to working with CMS as it establishes this code over the next year.”

The CMS intends to make medical groups with as few as 10 providers subject to its value-based payment in 2016, with payments reflecting performance in 2014.

Groups of 100 or more doctors will be subject to the modifier in 2015.

“Logically, people were looking for a jump down to around 25,” said Anders Gilberg, senior vice president for government affairs for the Medical Group Management Association. “That was a significant rebuke of the recommendations MGMA and other groups made to them.”

Practices that size, he noted, have been receiving performance feedback reports, and Gilberg described those reports as “a bit rough at this point.”

Gilberg recommended slowing implementation so that the initial data from the large groups can be analyzed and the program can be refined.

“It's like a grand experiment, value-based purchasing,” Gilberg said. “But they don't develop the next steps on the basis of the evidence. They just blindly go forward.”

In response to recommendations to pull back on the program, however, the CMS said in the regulations that doing so “would delay improving quality of care furnished by groups of 10 or more” providers to Medicare fee-for-service beneficiaries.

Follow Andis Robeznieks on Twitter: @MHARobeznieks