Medicare Opens New Revenue Stream for Doctors
In a change from earlier policy, the Department of Health and Human Services will soon begin authorizing Medicare payments to end-of-life care coordinators and those patients with two or more chronic medical conditions.
The move comes in response to growing evidence that patients who are suffering from terminal illnesses continue to suffer from poor care coordination and poor transitions between medical institutions, including nursing homes, hospitals and hospice facilities. The same applies to patients who are struggling with multiple medical conditions, even though they may not be specifically terminal, including not just physical ailments such as diabetes and cardiopulmonary diseases, but also mental illnesses such as depression.
Experts say that problems with care coordination for those patients with multiple medical issues frequently lead to needless medical errors – and further costs to the system.
Projected services qualifying for the $42 monthly payment include:
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- Medical assessment
- Social needs assessment
- Psychological assessment
- Medication compliance assessment
- Monitoring care by other physicians and health care professionals
- Planning for the smooth transition from care environment to home or to another care facility.
Doctors can begin earning monthly fees for managing care for these patients beginning in January. But there’s a catch: To earn the monthly payout, patients must have access to doctors or their staffs 24 hours per day, 7 days per week.
The 24/7 requirement was opposed by doctor’s interest groups as unrealistic for small practices, but the Obama Administration rejected their calls, citing the requirement as essential.
Depending on the practice, however, the policy could be an opportunity for some clinics to expand operations somewhat to keep a health care professional on staff 24/7 – depending on the patient mix. According to reporting from the New York Times, as many as 2/3rds of Medicare beneficiaries have two or more chronic conditions. This group of patients accounts for more than 90 percent of Medicare spending.
A recent article in the New England Journal of Medicine, by Matthew J. Press, M.D., a general internist, detailed the challenges of acting as care coordinator for just one 70 year old patient with a few minor medical problems until he was presented with probable cholangiocarcinoma in his liver.
Over the 80 days between when I informed Mr. K. about the MRI result and when his tumor was resected, 11 other clinicians became involved in his care, and he had 5 procedures and 11 office visits (none of them with me). As the complexity of his care increased, the tasks involved in coordinating it multiplied. I kept a running list and, at the end, created an “instant replay” of Mr. K.’s care.
In total, I communicated with the other clinicians 40 times (32 e-mails and 8 phone calls) and with Mr. K. or his wife 12 times. At least 1 communication occurred on 26 of the 80 days, and on the busiest day (day 32), 6 communications occurred.
Medical practitioners will have to assess their own patient mixes and decide if they can profitably provide this service for 24 hours per day, 7 days per week, for $42 per patient.
Patients will be expected to contribute 20 percent of the fee, so there remains a collection issue with these patients, as well as an administrative hurdle. The government asks that physicians participating in the program move to an electronic records system to facilitate transfers.
While the patient that Dr. Press describes is an outlier, it’s very easy to imagine a small practice or clinic trying to get involved in this program and biting off more than it can chew. The key is to have enough people in the program who are sick enough to qualify but not so sick that the requirements of care coordination overwhelm the available clinical staff.
However, without a steady stream of younger and healthier patients, physicians and clinic managers should take care to note that even if the patient mix indicates that participating in the program now would be profitable, that people get older and sicker over time. Be wary of the effect this would have on your practice, and manage your staffing accordingly.
However, for all the risks that participation presents to practice owners, there is potentially a significant opportunity for doctors, nurse practitioners and other health care professionals to offer their services as employees. The man-hours that will be necessary to run this program will be significant, however this is the most likely avenue of benefit for most young physicians.