Medicare will start compensating physicians for all the work they do to manage the chronic care of beneficiaries. Live, face-to-face encounters with patients will no longer be a requirement for payment.
It's just an extra $42.60 a month in pay for care provided to certain Medicare patients, but for primary care doctors it's a huge cause for celebration.
Yul Ejnes, MD |
Finally, Medicare has adopted a new code that pays physicians for the ton of work they and their staffs provide for millions of their sicker patients when the patients aren't seated in front of them.
Until the rule kicks in Jan. 1, a face-to-face encounter has been required for doctors to get paid.
The so-far unpaid work is the countless hours primary care doctors spend on tasks such as: reviewing lab reports and specialist consults, talking with family and patients by phone, arranging referrals, easing transitions, calming fears, correcting mis-information, straightening out nursing home issues, helping order medical equipment, and revising prescription drug orders. The more complex the patient, the more time spent.
"Until now, we've been doing this on our own dime—at the beginning or end of the day, during non-patient care hours—because we think it's important," says Rhode Island internist Yul Ejnes, MD.
"You can argue the payment amount isn't enough, or the requirements excessive. But at least it's a start. Medicare's… old party line that the visit encompasses all of this work done in between seems to be falling aside."
In the Physician Fee Schedule 2015 final rule, released Oct. 31, the Centers for Medicare & Medicaid Services says doctors may file claims for non-face-to-face care for Medicare beneficiaries with two or more chronic conditions, which is about 66% of all Medicare enrollees, according to CMS. The newly designed CPT code for this is 99490.
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It's unclear whether doctors treating patients with Medigap plans or Medicare Advantage plans will qualify. But even if they don't, physicians treating millions of beneficiaries could be eligible for a lot of extra pay.
There are caveats, of course. Doctors must prove to CMS that they provide management services 24/7, have electronic medical record documentation, and they must be able to create a "structured clinical summary record," with the patient's "full list of problems, medications and medication allergies."
They will also have to get the patient's consent to participate, (only one doctor per patient can get this $42.60) explaining why this service is necessary, and provide the patient with a care plan.
The chronic care management (CCM) code technically requires at least 20 minutes of CCM care per month, although frequently, the care involved will take a lot longer.
There remain significant hurdles to make this work positively for physicians' practices, and not be an administrative burden, says Reid Blackwelder, MD, board chairman and past president of the American Academy of Family Physicians. But, he says, the new code could result "in a substantial income per month for physicians taking care of these patients."
In his practice, for example, where one-third of his patients are on Medicare, non-face to face care he provides to about 60% of them might qualify for the $42.60 per month at least four to six months per year.
Another big issue in the new code's requirements is that beneficiaries will have to pay $8.52 as a Part B 20% co-pay, at least until their $147 deductible is satisfied. Normally, CMS pays for certain types of preventive care in full, without requiring a co-payment. But will patients say no because of the $8 co-pay? Blackwelder says they might. For many patients $8 per month is a lot of money.
But CMS says it won't classify these types of services as preventive because the U.S. Preventive Services Task Force has not given CCM an acceptable rating as a "preventive" service. "Since CCM does not meet the criteria, we cannot designate it as an additional preventive service," CMS says.
Besides, CMS says, "practitioners should explain that a likely benefit of agreeing to receive CCM services is that although cost-sharing applies… CCM services may help them avoid the need for more costly face-to-face services that entail greater cost-sharing."
Blackwelder says most doctors aren't yet aware of this code, because it was finalized just two weeks ago, and groups like his had despaired of getting the rule changed.
"But I hope when they find out now, they'll say 'Oh my God.' And figure out how they can build it into their practices if they can.""
The new code is not the first to pay for non-face-to-face care, but it is the first to do so exclusively. CMS had adopted a code for transitional care management, or TCM, which paid doctors for direct, telephone, or electronic contact with a patient or caregiver within two days of the patient's discharge, but that required at least one face-to face visit.
"This is the first one that is exclusively from non face-to-face work," Erickson says.
Blackwelder says the new CCM code comes at an important time in primary care because payment is threatened in so many ways. The 2% sequester and the Sustainable Growth Rate formula all loom.
Plus, the Medicaid parity payments specified in the Patient Protection and Affordable Care Act, which brought Medicaid primary care pay rates up to Medicare levels, expires Dec. 31, reducing Medicaid pay by as much as one-third in most states that don't have their own Medicaid/Medicare parity rules.
Shari Erickson, vice president of the American College of Physicians which has advocated for such a payment for at least two years, said her group is also pleased with the new CCM code.
She said in an e-mail that CMS expects doctors will be able to bill for CCM services about six months per year for qualifying beneficiaries. It's a lot of patients, she acknowledges, because "CMS estimated in 2011 that 93% of Medicare spending was for beneficiaries with two or more chronic conditions."
Plus, CMS modified its requirements. For example, physicians can qualify for the payment if they have a 2011 or a 2014 certified electronic health record system, not just one certified for 2014 as the agency had said in this proposed rule.
There also may be some cost for some practices that must invest in additional information technologies, and that could get expensive.
Hopefully, once doctors realize they are getting paid for the kind of care they give for free, they will give more of it. It's a good idea for everyone, saves money, and at last patients won't have to needlessly and inconveniently schlep to the office to get information they could have gotten by phone, simply because the doctor needed to get paid for it.