Even as Americans are living longer and physicians must devote an ever-larger proportion of their time to managing patients' chronic care needs, Medicare policy remains based on acute, episodic treatment with only a limited focus on care coordination.
The Senate Finance Committee is addressing this disconnect through a bipartisan working group headed by Sens. Johnny Isakson, R-Ga., and Mark Warner, D-Va., that is exploring ways to revise the delivery of chronic care for patients in Medicare, Medicaid and other government health plans. The working group sought input from the AAFP and other stakeholders on general policy options(www.finance.senate.gov) "to effectively target and better engage individuals with multiple chronic conditions" while also better aligning incentives to health care professionals "who engage in labor- and time-intensive patient care coordination."
In response, the AAFP outlined its support(10 page PDF) for revising evaluation and management codes, eliminating the monthly patient co-payment for chronic care management (CCM), expanding the use of telemedicine and changing the way patients join accountable care organizations (ACOs).
CMS' establishment of a code for CCM -- 99490, which pays an average of $42 per visit -- was a positive step, but the AAFP emphasized that one code is not broad enough to cover complex visits that require more time from a physician.
- A bipartisan working group of the Senate Finance Committee recently asked for suggestions to improve chronic care management for patients in public health care plans.
- The AAFP called for revising evaluation and management codes, eliminating monthly copayments, expanding the use of telemedicine and changing how patients join accountable care organizations.
- The working group aims to develop a legislative proposal in the next several weeks.
"Unfortunately, the current payment policy related to code 99490 represents a one-size-fits-all approach that ignores the fact that different patients will require different levels or intensities of CCM and thus will consume variable amounts of physician work and practice expenses," the letter reads.
Another major change the AAFP is advocating is a shift from fee-for-service payments alone to blended payments that include a monthly capitation payment for chronic care as well as fee-for-service for other physician services.
"Given the complexities inherent in CCM service codes, the AAFP sees it as indicative that care management is not well suited for a fee-for-service payment structure," the letter reads. "The AAFP urges CMS and other payers to move as soon as possible to a risk-adjusted, capitated, monthly payment for primary care management services."
In response to the senators' request for suggestions on how to ensure patients will visit physicians for chronic care needs, the AAFP noted that eliminating some patient out-of-pocket expenses would help.
"Under the CCM code, absent supplemental coverage, the beneficiary is responsible for copayment of about $8 a month, whether or not the patient sees the doctor in a separate face-to-face encounter," the letter reads. "This has led to beneficiary confusion and to the administrative difficulty of collecting the beneficiary's share of the payment. Some beneficiaries also are unable or unwilling to enroll in a recurring monthly service that carries an additional patient charge."
The AAFP also noted that if payment reform efforts are to succeed in reducing unnecessary hospital visits, then CMS and other payers need to offer stronger support for telemedicine. There is little incentive in Medicare Advantage to expand the use of telemedicine under current policy, but by raising the issue in its policy options document, the Senate working group signaled a potential for change.
"Regarding eligibility for payment, it should not matter whether a patient service is rendered in person or through telemedicine," the AAFP said in its response. "If it is a valid service, it should be paid whether it was performed face-to-face or virtually."
CMS also needs to change the way patients join ACOs, said the AAFP. Currently, most patients are assigned to an ACO without their input, meaning physicians often do not know who their patients are and cannot set up population management strategies. Instead, patients should be able to choose their primary care physician and the ACO in which they wish to participate.
Within the ACO structure, the AAFP recommended that physicians receive a global payment for direct patient care that would cover most services during an office visit. Any additional services would be paid either on a fee-for-service basis or as part of another bundled payment. A separate global care management fee would cover coordination of care services.
The working group will review the responses to the policy options, with the goal of developing a legislative proposal in the next several weeks.
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