CMS care-man­age­ment fees help med­i­cal home prac­tices

Modern Healthcare - - NEWS - By An­dis Robeznieks

If a chron­i­cally ill Medi­care pa­tient stops tak­ing his med­i­ca­tion, Dr. Jim King finds out about it within a week.

That’s be­cause one of his staff calls to find out, learns why and then fol­lows up to rem­edy the is­sue.

This way of work­ing has im­proved the health of his pa­tients and saved— even earned—his prac­tice money.

Since Jan­uary, the CMS has cov­ered monthly ex­penses for chronic-care man­age­ment of pa­tients not con­ducted dur­ing a face-to-face pa­tient visit.

The CMS re­ported that about 35 mil­lion Medi­care ben­e­fi­cia­ries are el­i­gi­ble to re­ceive th­ese bill­able care-man­age­ment ser­vices. But the agency has re­ceived re­im­burse­ment re­quests for only about 100,000.

Com­plaints about the chronic-care man­age­ment re­im­burse­ment pro­gram vary from lengthy doc­u­men­ta­tion to hav­ing to have a dif­fi­cult con­ver­sa­tion with pa­tients who now are re­spon­si­ble for a 20% co­pay­ment for pre­vi­ously free ser­vices.

Pri­mary-care ad­vo­cates hoped the care-man­age­ment fee would trans­form some prac­tices, en­cour­ag­ing them to in­vest in in­fras­truc­ture and adopt a team-based model of care.

And that’s hap­pen­ing for some, like Dr. King.

He’s hired a reg­is­tered nurse, two li­censed prac­ti­cal nurses and a clerk to join the five doc­tors and six nurse prac­ti­tion­ers at his three-clinic prac­tice in ru­ral western Ten­nessee. The Prime Care Med­i­cal Cen­ter staff are now mak­ing fol­low-up calls, mon­i­tor­ing pa­tient-care plans, re­view­ing test re­sults and con­sult­ing with the pa­tients’ other providers.

For the CMS to pay for those pa­tient calls, they must add up to at least 20 doc­u­mented min­utes a month. King said calls vary widely, with as few as 17 min­utes one month to 70 the next. Also, sev­eral min­utes of un­paid prepa­ra­tion are of­ten done be­fore call­ing a pa­tient. The CMS’ av­er­age monthly re­im­burse­ment per pa­tient is $42.

“It’s not go­ing to be a wind­fall,” said King, the former pres­i­dent of the Amer­i­can Academy of Fam­ily Physi­cians. “But it’s an­other tool to help us take care of our pa­tients.”

Prime Care has care-man­age­ment pa­tients with di­a­betes, hy­per­ten­sion, heart dis­ease, chronic ob­struc­tive pul­monary dis­ease and hy­per­lipi­demia. Pa­tients with arthri­tis and other chronic con­di­tions will be added later.

About 150 to 200 pa­tient en­coun­ters a month fall un­der the chronic-care man­age­ment rubric, and King said they need at least 200 to break even. “It’s go­ing up steadily as we un­der­stand bet­ter what we need to do to doc­u­ment the en­coun­ters. Our goal is to get to 300 and that will jus­tify do­ing this.”

An An­nals of In­ter­nal Medicine prac­tice-mod­el­ing study pub­lished on­line in Septem­ber showed a “typ­i­cal” prac­tice with about 2,000 Medi­care pa­tients could gen­er­ate more than $75,000 net rev­enue per full-time physi­cian if half of their el­i­gi­ble pa­tients en­rolled in chronic-care man­age­ment. They cal­cu­lated that if a prac­tice hired a reg­is­tered nurse to work full time on care man­age­ment, it would need to en­roll at least 131 Medi­care pa­tients to break even. If they hired a li­censed prac­ti­cal nurse, they would need to en­roll 76.

Prime Care em­braced chronic-care man­age­ment in part be­cause it was an early adopter of the pa­tient-cen­tered med­i­cal home prac­tice model, a team­based prac­tice that con­cen­trates on pro­vid­ing co­or­di­nated care. All of the Prime Care clin­ics are rec­og­nized by the Na­tional Com­mit­tee for Qual­ity As­sur­ance. One car­ries the group’s high­est rat­ing.

Med­i­cal home prac­tices are at an ad­van­tage in meet­ing the care-man­age­ment re­quire­ments, which in­clude ob­tain­ing pa­tient con­sent, record­ing data in a stan­dard­ized for­mat, and cre­at­ing a care plan with an ex­pected out­come, mea­sur­able goals, and strate­gies to man­age symp­toms and med­i­ca­tion. But the de­tailed doc­u­men­ta­tion needed has led to crit­i­cism that chronic-care man­age­ment is just an­other pa­per­work-gen­er­at­ing gov­ern­ment pro­gram.

“We’re con­cerned about whether we’re just check­ing boxes or are we re­ally mov­ing the nee­dle on im­prov­ing health,” King said. “I’m not sold on every­thing yet, but the only way you’ll know is if you give it a try.” King said he

and his part­ners will re-eval­u­ate their par­tic­i­pa­tion this De­cem­ber.

The CMS has rec­og­nized the per­ceived short­com­ings as­so­ci­ated with this new billing code and has asked for ways to im­prove.

The Fam­ily Medicine Clin­ics of the mu­nic­i­pally owned, Avera-man­aged 25-bed Floyd Val­ley Hospi­tal in Le Mars, Iowa, are an NCQA-rec­og­nized pa­tient-cen­tered med­i­cal home. The seven physi­cians, two physi­cian as­sis­tants and two nurse prac­ti­tion­ers each run their own care teams con­sist­ing of two RNs or LPNs as clin­i­cal as­sis­tants plus a pa­tient-ser­vices coach.

Clinic Ad­min­is­tra­tor Julie Sitz­mann said that means they can de­liver the re­quired care-man­age­ment ser­vices. But they aren’t us­ing the code be­cause of the resources needed to com­plete the doc­u­men­ta­tion. “At first sight, your thought is, ‘For 40 bucks you want us to do all this?’ For­get it,” Sitz­mann said. “Then you read closer, and it’s stuff we’re al­ready do­ing—and doc­u­ment­ing.” But the clin­ics’ EHR is not set up to record the minute-by-minute level of doc­u­men­ta­tion re­quired, so they’re tak­ing a pass.

Dr. Mark Belfer, chief med­i­cal of­fi­cer of the 1,350-mem­ber Greater Rochester (N.Y.) In­de­pen­dent Physi­cian As­so­ci­a­tion wants the CMS to do a bet­ter job of ad­ver­tis­ing the code.

In fact, a sur­vey of 300 pri­ma­rycare physi­cians by tech startup Smartlink found that two-thirds of them were un­aware of the pro­gram or un­fa­mil­iar with its de­tails. The sur­vey also found that al­most half of the doc­tors said they were “wait­ing for cor­po­rate to de­cide” whether they would par­tic­i­pate.

That find­ing re­flects what’s hap­pen­ing in sys­tems like Uni­tyPoint Health, a West Des Moines, Iowa-based sys­tem with $1.9 bil­lion in rev­enue in the first half of 2015. It’s about to launch a pi­lot at one of its 240 clin­ics next month.

The ma­jor­ity of Uni­tyPoint clin­ics in Iowa, Illi­nois and Wis­con­sin have been rec­og­nized as med­i­cal homes and are do­ing the chronic-care co­or­di­na­tion re­quired to get CMS pay­ment, said Linda Wendt, Uni­tyPoint’s ex­ec­u­tive di­rec­tor of qual­ity. But there’s a hangup. “We want to be payer-ag­nos­tic,” she said. “You’d be sur­prised to find out how of­ten med­i­cal groups are asked to seg­ment pa­tient pop­u­la­tion by payer.”

Sioux Falls, S.D.-based San­ford Health has 250 clin­ics across nine states, and it also is al­ready ful­fill­ing the CMS re­quire­ments. It will start seek­ing re­im­burse­ment from the CMS for its chronic-care man­age­ment pro­gram by the first of next year.

Martha Le­clerc, San­ford’s vice pres­i­dent of rev­enue man­age­ment, wants the pa­tient co-pay to end. “Long term, this pays for it­self through re­duced com­pli­ca­tions, re­duced read­mis­sions, and re­duced emer­gency depart­ment vis­its,” she said. “We can­not af­ford for them to not have this ser­vice.”

While much of the work is un­com­pen­sated, Le­clerc said com­mer­cial in­sur­ers such as the Min­nesota and North Dakota Blue Cross and Blue Shield plans are al­ready pay­ing for chronic-care man­age­ment and with “doc­u­men­ta­tion re­quire­ments that are less oner­ous than CMS.”

She added that Min­nesota Med­i­caid is also pay­ing a com­pa­ra­ble fee for care man­age­ment, but with­out a co­pay. She added that most com­mer­cial plans pay be­tween $45 and $50 for man­ag­ing pa­tients with two chronic con­di­tions and even more if a pa­tient has five or more chronic con­di­tions.

At CHI Fran­cis­can Health, based in Ta­coma, Wash., they’re test­ing a small, di­a­betic-fo­cused, team-based pi­lot us­ing a care man­ager, clin­i­cal phar­ma­cist and di­a­betes ed­u­ca­tor.

Sherry Aliotta, as­so­ciate vice pres­i­dent for care co­or­di­na­tion at the Catholic Health Ini­tia­tives-af­fil­i­ated sys­tem, said it em­beds care man­agers at its med­i­cal homes and has in­vested in ed­u­cat­ing nurses to fill th­ese roles. With com­mer­cial plans and now the CMS pro­vid­ing pay­ment, there’s money to sup­port the staffing re­quired for a suc­cess­ful chronic-care man­age­ment pro­gram, Aliotta said. She set up her first care-man­age­ment pro­gram in 1995.

“One of the things that has been a bar­rier is the cost to pro­vide this ser­vice with­out a clear re­turn on an in­vest­ment,” Aliotta said. “So there’s al­ways some­one ask­ing ‘Do we re­ally need th­ese peo­ple?’ ”

King noted that it’s not nec­es­sar­ily more or less work—it’s dif­fer­ent work.

“In­stead of one visit ev­ery month, it may be ev­ery two or three months,” he said. But in­stead of send­ing out let­ters with lab work, we’re hav­ing a nurse call to make sure pa­tients un­der­stand it. It’s less face to face, but more hands-on.”

A San­ford di­eti­tian, right, ad­vises an Iowa pa­tient as part of its ex­ist­ing care­m­an­age­ment pro­gram. It plans to start billing Medi­care only early next year.

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