In 2015, Medicare beneficiaries (65 and older) accounted for only 15% of the population but 34% of annual healthcare expenditures. Medicare spending steadily increases as beneficiaries age, in part due to the management of multiple chronic conditions (MCC) that require primary and specialist care, medication, and/or hospitalization, among other health expenses. MCC, or comorbidities, affect nearly one in four Americans. Chronic conditions include physical conditions (i.e. arthritis, cancer, hypertension, high cholesterol) and mental/cognitive conditions (i.e. dementia, depression, substance abuse) that last longer than one year and require continual medical attention and/or impact daily activities. According to a recent RAND report, 81% of those over 65 have MCC, including nearly two-thirds of Medicare beneficiaries.
Care for those with MCC is frequently fragmented and can lead to contradictory advice and prescriptions, as well as general confusion about treatment and outcomes among older patients. To promote integrated care of complex Medicare patients in primary care, CMS introduced a Chronic Care Management (CCM) service in 2015.This fee, about $40 a month per qualified patient, marked a shift from reimbursement for providing in-office services to non-face-to-face care management/oversight, including the creation of a care plan, coordination/follow-up with a patient’s other providers, monitoring medication, and offering 24 hour access to a member of the care team. Over 684,000 beneficiaries received CCM services during the first two years (2015-17). A CMS report found that baseline Medicare expenditures decreased due to this fee and that the rate of growth for ED visits/hospitalizations decreased; the rate of primary care visits increased.
The recently released 1,500 page proposed 2019 Medicare Physicians Fee Schedule and Quality Payment Program from CMS presents two changes to physician payment that might greatly affect care of those with MCC across specialties.
Condensing evaluation and management (E/M) visit codes
This set of billing codes, ranging from level 1 (nonphysician services) to level 5 (the most complex cases), are used by doctors use to distinguish the complexity of care provided during a visit. For new patients, Medicare pays physicians between $76 (level 2) and $211 (level 5); established patient rates are $22 for a level 2 up to $148 for a level 5. The proposed rule would condense levels 2, 3, 4, and 5 into one level with a payment rate of $135 for new patients and $93 for established patients. [Level 1 is not included in the CMS proposal.] The rule would allow providers to use add-on codes to receive enhanced compensation for a more intense patient visits (longer visit time), but proposed reduced documentation requirements for complex visits could lead to abuse, and higher expenditures.
Physicians groups have raised concerns about underpayment for providers who care for a disproportionate number of high-acuity, complex patients. CMS estimates that while most providers will see a 1-2% increase or decrease in payment, cardiologists, oncologists, and neurologists would see a 3% cut, rheumatologists would see a 6% cut, and endocrinologists would see an 8% cut.
Mobile health technology for check-in visits and remote evaluation
CMS has proposed new billing codes to pay providers for “prolonged preventive services,” as well as three new codes to reimburse remote monitoring of images and videos sent by patients. Medicare would pay $14 for brief virtual check-ins, such as a phone call or video chat, to decide whether an office visit or other service is needed. [A good example of using telehealth to assess what level of care is needed is the JeffConnect program in Philadelphia. This is not the type of telehealth is proposing to reimburse, but it’s a possible model for future telehealth care.] To receive reimbursement, the proposed rule requires an established doctor-patient relationship. This could reduce unnecessary and/or avoidable office visits, ER trips, and hospitalizations for those with MCC, diminishing their risk of infection (or infecting others, depending on their complaint). It is unclear if the Medicare population will take full advantage of this service, particularly video chat, but it could be an opportunity to explore the benefits of telehealth on outcomes and expenditures if providers are given adequate support to fit this into their busy day when appropriate.
Follow this link to view the proposed rule in its entirety and provide CMS with your thoughts. Public comments on the proposed rule are due by September 10, 2018.