Bridg­ing the di­vide

RUC rec­om­mends pay­ment for care co­or­di­na­tion

Modern Healthcare - - THE WEEK IN HEALTHCARE - An­dis Robeznieks

An in­flu­en­tial com­mit­tee that makes physi­cian pay rec­om­men­da­tions to the CMS ap­peared to take a ma­jor step to­ward com­pen­sat­ing pri­mary-care prac­tices for med­i­cal man­age­ment ser­vices and re­dress­ing the im­pres­sion that the panel fa­vors spe­cial­ists.

In an Oct. 3 let­ter to CMS Ad­min­is­tra­tor Dr. Don­ald Berwick, the panel—of­fi­cially the Amer­i­can Med­i­cal As­so­ci­a­tion Spe­cialty So­ci­ety Rel­a­tive Value Scale Up­date Com­mit­tee and com­monly re­ferred to as “the RUC”— rec­om­mended pay­ing for care-co­or­di­na­tion ser­vices such as tele­phone time, an­ti­co­ag­u­lant man­age­ment to pre­vent strokes and group pa­tient ed­u­ca­tion ses­sions.

The RUC has come un­der fire in re­cent years for un­der­valu­ing pri­mary-care ser­vices and for be­ing the cause of the widen­ing in­come gap be­tween pri­mary-care physi­cians and “pro­ce­dural spe­cial­ists,” but the let­ter noted the ris­ing im­por­tance of care co­or­di­na­tion and how it needs to be re­warded.

“An im­me­di­ate so­lu­tion to in­cen­tivize care co­or­di­na­tion is re­quired, and it is, there­fore, crit­i­cal that medicine and CMS work closely to­gether to en­sure con­sen­sus and ef­fec­tive im­ple­men­ta­tion,” RUC Chair­woman Dr. Bar­bara Levy said in the let­ter. In a news re­lease, Levy said that “By ac­cept­ing this rec­om­men­da­tion, CMS can take a crit­i­cal first step by Jan. 1 to rec­og­nize these im­por­tant ser­vices pro­vided by physi­cians who care for chron­i­cally ill pa­tients.”

Dr. Glen Stream, pres­i­dent of the Amer­i­can Academy of Fam­ily Physi­cians, said he saw the rec­om­men­da­tions as an in­terim mea­sure serv­ing as a bridge be­tween an old sys­tem that un­der­val­ues pri­mary care and a more com­pre­hen­sive plan that rec­og­nizes the value of care co­or­di­na­tion. But he added that he could see the CMS re­ject­ing the rec­om­men­da­tion on pay­ing for phone calls. “Are peo­ple go­ing to make more phone calls now that they are get­ting paid for them?” he asked. “That’s how the CMS will view it.”

The AAFP also has for­mally re­quested the RUC al­ter its mem­ber­ship to al­low more pri­mary-care rep­re­sen­ta­tion. And it has cre­ated a task force to de­ter­mine a more ac­cu­rate as­sess­ment of pri­mary-care ser­vices’ value.

Dr. Paul Fis­cher, who cre­ated the web­site re­placetheruc.org and is su­ing HHS and the CMS for re­ly­ing on the RUC’s ad­vice, called the care-co­or­di­na­tion sug­ges­tions “pa­thetic.” “They should be em­bar­rassed about it,” said Fis­cher, the founder of the Cen­ter for Pri­mary Care, a prac­tice of 30 fam­ily physi­cians in Au­gusta, Ga.

Fis­cher’s big­gest crit­i­cism was for the rec­om­men­da­tion to cre­ate three new codes for tele­phone time with pa­tients: One for 11 to 20 min­utes of med­i­cal dis­cus­sion, an­other for 21 to 30 min­utes and an­other for five to 10 min­utes, as long it was “not orig­i­nat­ing from a re­lated E/M (eval­u­a­tion/man­age­ment) ser­vice pro­vided within the pre­vi­ous seven days nor lead­ing to an E/M ser­vice or pro­ce­dure within the next 24 hours or soon­est avail­able ap­point­ment.”

That would re­quire physi­cians to keep a stop­watch by their phones, Fis­cher said, and “the doc­u­men­ta­tion would be more ex­pen­sive than what we would get paid.” It also would per­pet­u­ate the fee-for-ser­vice busi­ness model, he said, in con­trast with a com­pre­hen­sive monthly care-man­age­ment fee based on a pa­tient’s age and health sta­tus that cov­ers “every­thing we do that’s not done in an exam room.”

Fis­cher and his five med­i­cal part­ners filed a suit in the U.S. District Court in Bal­ti­more al­leg­ing, among other things, that HHS and the CMS are vi­o­lat­ing the Pa­tient Pro­tec­tion and Af­ford­able Care Act by us­ing an “un­char­tered and un­of­fi­cial” com­mit­tee to de­ter­mine the CMS fee sched­ule.

Pri­vate pay­ers, mean­while, are also mov­ing to cover care co­or­di­na­tion. Blue Cross and Blue Shield As­so­ci­a­tion is­sued an ac­tion plan Oct. 4 that called for “re­in­forc­ing front-line care,” and es­ti­mated that be­tween $105 bil­lion and $125 bil­lion could be saved over the next 10 years by mov­ing to­ward wide­spread adop­tion of the med­i­cal home-care model that would pro­vide bet­ter care co­or­di­na­tion.

The plan high­lighted care-co­or­di­na­tion ef­forts by Hori­zon Blue Cross and Blue Shield of New Jersey, which re­im­bursed doc­tors for tele­phone time and used claims data to alert physi­cians when pa­tients were due for tests and screen­ings. Ac­cord­ing to the as­so­ci­a­tion, over­all costs dropped by 10% in one year.

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