Posts Tagged primary care
Doctors have long complained they don’t get paid to solve problems over the phone. Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)
If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service. Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.
Who actually does all the work? The office nurse. The doctor supervises the decision making.
You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect. Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.
If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”. I will continue visits as usual.”
In general, CCM is a good thing. Here are some of the problems it solves: Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit. If your visiting nurse suggests some course of action then you go for an office visit. If you want to see a specialist you first go for an office visit. If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered. With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.
The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person. Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:
- Transitional care management: meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
- Supervision of home healthcare. The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
- Hospice care supervision.
- Provide a limited number of end-stage renal disease services.
The provider must have 5 capabilities and use those capabilities as needed:
- Keep your records in a computer
- Create a care-plan — an outline of goals and actions the provider will follow to meet those goals. Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
- Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record). Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
- Facilitate transitions in care. Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit. Or, keeping orders for home oxygen up to date. Or, immediately sending outpatient medical records to the hospital where you are admitted.
- Coordinate care. This does not mean providing all care, it is not a wall around you. If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you. And, follows the instructions of the specialist (as medically reasonable). Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service. And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).
CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day. It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.
Disclaimer: the rules and fees for this program are in a state of flux. What is true today may not be accurate tomorrow. So, discuss the meaning of CCM with your primary care provider. Give them a copy of this article as a place to start a discussion. Here are some additional helpful links:
Wow, you could have had a CPT code and $60. While fee-for-service is widely excoriated for excessive cost what is CMS doing? They want primary care providers or someone to have another fee-for-service. The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss. Both things that are currently part of an office visit with no additional CPT code — just good patient care.
Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time. CMS: don’t be so lazy — make the patient education video and tell primary care providers the URL! And, update the video every 6 months.
The bottom line:
- Lung Cancer CT Screening:
- Don’t do it if the patient can’t have surgery
- Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
- Don’t do it if the patient is less than 55 or over 80 years old.
- Don’t do it if the patient quit smoking more than 15 years ago.
- Weight-loss counseling:
- Say in a loud voice “you weigh too much” then say “eat less”. (that was not so hard!)
- Doctors have been doing this for decades without sustained results.
- There are 20,000 books about diets to loose weight without sustained results.
- This is not going to work — at least be honest.
Follow the money:
Counseling fees for CT scans is an incentive to do the CT scans. The primary care provider makes money, the x-ray office makes money and the radiologist makes money. A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain. Better yet — make it a provided service under an ACO plan!
Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral. The Primary care provider makes money (and changes from a primary care provider to a specialty provider). The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people. A better idea is not to add another CPT code. If the patient needs more time — make another appointment!
Happy doctors seeing fewer patients and making more money — what’s not to like? According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.
The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork. So, they developed a model of care where the patient pays $65/month and receives all the primary care they need. And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article). Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.
The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss. For the libertarian-minded physician it’s nirvana.
Piece-work is indeed a hard life as physicians and many in the garment industry know. A monthly salary is much easier on the worker. And, the salary model is not new in terms of primary medical care. The physicians working for the National Health Service (NHS) in the UK have had this system since WWII. However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work. And, they found it necessary to monitor quality since quality slips without oversight.
So, this “Direct Primary Care” is not new in the world. In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US. But, physicians need to realize they need to be part of a large organization to ensure quality care. The future for primary care is to be an employee, not a mom-and-pop store. Most of doctor’s patients work as employees, is that so bad?
$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!) So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?
- Measure and report quality in a transparent way — like on the office website. And, keep it updated.
- Deliver patient-centered care and prove it. Survey patient’s expectations and record whether the expectations are met with office visits.
- Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
- Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
- Take a financial stake in what is prescribed or ordered. Pay some fraction of the cost of all medications prescribed and all tests ordered. They need to have some “skin in the game”. (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).
Here are two simple things hospitals could do to reduce readmissions: 1) Make a primary care appointment for hospital follow-up at the time of discharge 2) Dispense enough of the patient’s medications to last until the primary care appointment or to last 2 weeks, whichever is longer.
Patients are often readmitted because they did not take the medications prescribed at discharge. The beauty of the suggestions: hospitals save money since the cost of medications is low by comparison to readmission, patients will likely take the medications they are given, primary care providers will be engaged, and there is a financial incentive to make the appointment within 2 weeks.