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CMS changes impacting primary care for the better


A look at how Medicare is reforming primary care payment.

The U. S. Centers for Medicare & Medicaid Services (CMS) is increasingly willing to increase reimbursement rates for managing the care of high-need, high-cost patients with chronic conditions, according to a new report by the Robert Wood Johnson Foundation and Urban Institute revealed.

Additionally, Medicare is adding new billing codes to the Physician Fee Schedule that can be used to pay for the behind-the-scenes calls, emails and faxes that are often exchanged to manage the care of a complex patient or coordinate a patient’s transition out of the hospital.   

For example, prolonged E/M service without face-to-face contact with a patient, conducted before and/or after direct patient care and lasting 31–60 minutes now has a fee schedule of $131.41.


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This is noteworthy because until a few years ago, Medicare didn’t pay doctors for tasks that weren’t part of a face-to-face visit-things like taking a phone call from a patient after hours, or communicating with other providers about a patient’s care.

Studies have found that a quarter to half of a primary care physician’s day is spent on activities that were not usually billable, says Rachel Burton, MPP, one of the authors of the report and a senior research associate for the Urban Institute in Washington, D.C.

“But new Medicare billing codes like the Chronic Care Management billing codes, which became available in 2015, are allowing physicians to get paid for this type of work-as are demonstrations like CMS’s Comprehensive Primary Care Plus (CPC+) model,” she says. “These new revenue sources could help increase incomes of primary care practitioners and attract more physicians to primary care specialties.”

As noted in the report, 69 percent of traditional Medicare beneficiaries have multiple chronic conditions, yet they generate 93 percent of Medicare spending.

“Providers should start making a point of asking the payers, health plans and networks they contract with what tools and services will be available to help better manage patients with chronic illnesses,” says Scott McFarland, president of HealthBI, a population health technology company based in Scottsdale, Ariz. “Bottom line: Successful management of such populations requires access to the right data-real time data that shows whole patient health.”

Next: Benefits for primary care


Benefits for primary care

Savvy physicians can take advantage of this opportunity to both increase revenue and help patients.

“Primary care providers can now hire staff like nurse care managers to focus on more closely monitoring their most complex patients, and they can use new Medicare billing codes to pay for this,” Burton says. “New billing codes are available for staff time spent managing patients’ transitions out of the hospital and managing complex patients’ care on an ongoing basis-even in months when the patient doesn’t come in for a visit.”

Collectively, these capabilities will be at the core of any care delivery model aiming to face the 21st century population health demands.


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“To realize the potential financial and patient health gains represented by CMS’ growing investment, physicians should not only seek to master the comprehensive primary care functions CMS requires they perform, but also aggressively focus on developing processes for uncovering the broader behavioral, social and environmental factors driving patients’ poor health, and collaborating across specialties, sectors and communities to address them,” says Rebecca Fogg, senior research fellow for healthcare at the Clayton Christensen Institute in Boston.

Overcoming Challenges

There are challenges to the incremental approach identified by the Urban Institute, such as the trend toward uncoupling fee-schedule activity from the daily coordination piecework of primary care, says Scott Cullen MD, principal of ECG Management Consultants in Boston.

Next: "The time is now"


“On its face, this lowers the administrative burden for tracking payment all around; however, the risk with this approach is that we essentially move PCPs toward a model of ‘capitation without risk’ and remove the incentive to account for productivity,” he says. “While this may allow for a more efficient focus on quality and coordination, we also leave specialists in a traditionally volume-driving fee-for-service model. This is unlikely to be successful in reducing overall cost.”

Another major issue he sees is this approach’s identified lack of accountability on the part of the physicans in reducing the overall cost of care for the population.


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“Arrangements in which the primary care physicians is most effective in controlling overall costs generally exist only when they are at risk for overall cost to some degree,” Cullen says. “Although ACO models are moving gradually in this direction, experience there has been mixed; better evidence of this phenomenon exists in our experience with physician-driven networks taking on contracts for the full cost of care, even with Medicare beneficiaries.”

A challenge to taking full advantage of what CMS is offering, Burton says, is that demonstrations only accept new applicants during specific defined periods and from certain geographic areas. For example, it’s too late to join the CPC+ demonstration, and it’s only available in 18 regions of the country.

McFarland notes it’s important to emphasize to providers what a generational opportunity this is for them.

“Those providers that thrive on helping even the most complex patients experience a better quality of life have a chance to do that for entire populations now, thanks to new shared data platforms and a willingness among payers to provide that technology free of charge,” he says. “And really, the time is now. We’ve never had more patients more in need of comprehensive care that keeps their chronic illnesses in check.”

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