AMA Cries for More Cash to Ensure Quality Care

The American Medical Association wants the Centers for Medicare & Medicaid Services to start paying doctors extra for care coordination. The group argues in a letter to CMS administrator Donald Berwick that four types of care coordination services should be reimbursed separately from the office visit to ensure physicians are compensated for providing these services.

Before I criticize their position, I want to note that their argument, on its face, is sound. Care coordination, in many cases, does prevent more expensive hospital care down the road. That's because, in theory, patients aren't made sicker because of poor communication among their various doctors, usually one or more specialists in addition to a primary care physician.

The idea is to get all the providers actually communicating with each other instead of each operating within their own silos, thereby possibly endangering the patient with incompatible drugs, treatments, or conflicting advice.

And taking care of these kinds of patients is more difficult and time consuming than treating healthier ones, while both are reimbursed at the same rate. But that's where my agreement with their position ends.

Excuse me, but as physicians sworn to do no harm, isn't this kind of work what they should be doing already? The presupposition in their argument is that physicians' responsibility for overall quality patient care begins and ends at coding.

To take their argument further, perhaps they should be reimbursed separately for writing a prescription when the patient is not in the room? The fact that many physicians don't currently coordinate care is just one indication of why our national healthcare bill is frighteningly large and rapidly growing larger. Of course, patients have some responsibility for coordinating their own care, but clearly, most don't have the ability to do this job on their own.

My point is that just because a payer happens to be a relatively poor one, the government, which now expects more value for its money, doesn't mean you necessarily get to break down your responsibility to provide quality patient care into tinier and tinier bits so that each step in the process is reimbursable.

If you can't make a decent living servicing these patients under the reimbursement system that is currently in place, why not lobby for an overall increase in reimbursement, or better yet, just stop taking new Medicare patients? (My understanding, anecdotally, is that this is happening at a higher and higher rate. Dropping Medicare patients instead of arguing for reimbursement for things that most patients feel you should be doing anyway should eventually solve the problem as seniors, who vote, complain to their legislators). But let's not pretend that the reason healthcare has a big hand in bankrupting us all is because we haven't thrown enough money at it or broken it down into smaller and smaller reimbursable steps.

Look, I'm not suggesting that extra work doesn't go into caring for Medicare beneficiaries who have multiple illnesses. They are a difficult group, and it's OK that the AMA and its members are asking and lobbying for extra payment, but geez, can you imagine the way a system like this could be gamed?

I could be wrong, but I doubt a plea like this will fall on willing eyes and ears at CMS, which is actively discouraging fragmentation of healthcare, not abetting it.

Can't we all agree that fee-for-service healthcare reimbursement is a failure in the sense that patients aren't best served by piecemeal delivery and lack of care coordination? And shouldn't we all agree that once and for all, patient care shouldn't stop at the office door? The whole thing makes my head spin and long for capitation, as many problems as that created.

I don't fault the AMA for trying, but the effort represents clinging to a model of reimbursement that is antiquated, wasteful, and provides strange incentives that seem to absolve doctors of the responsibility for taking care of anything regarding these patients other than what will be reimbursed.

The system is broken. But more fragmentation of the care process will only make it worse. And this isn't leadership.

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