Bridging the divide
RUC recommends payment for care coordination
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.