AMA Asks Medicare to Start Paying Doctors for Care Coordination

The American Medical Association wants Medicare to start paying doctors for four types of coordination services because they avoid more expensive patient care in the hospital down the line.

The services include responding to telephone calls seven days or more after a patient sees the doctor, education and training to enable patients to better manage their own health, better management of anticoagulation drugs such as warfarin, and time spent coordinating team-based care when the patient is not present.

In a letter last week to Centers for Medicare & Medicaid Services Administrator Donald Berwick, MD, the AMA explained that these services fit into a general category of chronic care coordination, which if incentivized with dedicated effort, would improve quality of care and avoid more costly hospitalizations, especially for patients with multiple co-morbidities. Some of these services are now provided by doctors, but they do it for free or with money paid for a previous visit.

 “When treating patients with chronic conditions, such as heart disease and diabetes, physicians provide many services that are currently not recognized or compensated by Medicare," wrote Barbara Levy, MD, chairperson of the AMA's Specialty Society RVS (Relative Value Scale) Update Committee, known as the RUC. The AMA's RUC makes recommendations on how various types of physician services should be valued and paid by a variety of payers, and 94% of those recommendations have been upheld by CMS.

"Not only will payment for these services save Medicare money in unnecessary office and emergency room visits," Levy wrote in the letter, "potential savings in Medicare Parts A and D will also offset upfront payment for non–face-to-face services."

Levy added that the AMA's Chronic Care Coordination Workgroup, which settled on these recommendations, will continue meeting to consider longer-term changes that can "appropriately recognize physicians' work on patient care coordination and the prevention and maintenance of chronic diseases."

Levy's letter says the recommendations are of "immediate urgency" because the 2012 Medicare Physician Payment Schedule, which is now in draft form, will be finalized in November, setting payment policies starting Jan. 1, 2012. The draft version does not include any mechanism for paying doctors who coordinate care of Medicare patients.

The annual cost of paying physicians more for these services would be about $200 million, but that amount would be offset by savings from a major review last year in which the RUC reclassified certain overvalued physician services, the AMA contends.

For example, before this review, radiologists performing CTs of both the pelvis and the abdomen could bill under two separate billing codes, when in fact not much more work was required. Now those codes are bundled.

More than $1 billion was redistributed in physician payments last year, and the AMA believes some of those savings could be used to pay for care coordination when it requires a physician's expertise rather than a nurse's.

"The RUC's work on misvalued codes provides an opportunity to offset the costs [of the new recommendations], negating any impact to the Medicare conversion factor," Levy wrote.

The four types of services in the new recommendations are:

1. Anticoagulant management— According to the RUC, payment for this service "would result in a nominal payment ($41 per month for initial 90 days and $14 per month for subsequent 90 days of management." CMS has previously considered these services bundled into the cost of evaluation and management (E&M) for the office visit, and not paid separately.
2. Education and training for patient self-management—Levy gave the example of a patient with an established illness or disease, such as diabetes or asthma, who is referred by a physician to a qualified, non-physician health professional for education and training to delay co-morbidities. "These services are clearly separate and distinct from E&M, requiring 30 minutes of education provided by non-physician clinical staff."
3. Medical team conference—Levy wrote that when a physician’s involvement in a team conference with the patient and other health professionals may qualify as E&M. "However, if the patient is not present...no separate reporting is allowed by Medicare. Non-physicians, such as dieticians, physical and occupational therapists, are not allowed to separately report the time that they spend in team conferences, whether the patient is present or not."
4. Telephone services—If a consultation by telephone ends with a decision to see the patient within 24 hours or next available urgent-visit appointment, the code would not be reported and considered part of the subsequent E&M service, procedure, and visit, or if within seven days of a prior visit, the AMA suggests. The number of these phone calls could be capped, or limited to those just initiated by the patient.

Immediate implementation of the AMA’s recommendations “would signal that CMS is serious about providing incentives for care coordination," Levy's letter says.