While still shrouded in mist, the path to transforming our health care system is becoming more clear.While the view is still hazy, last week the Centers for Medicare and Medicaid Services (CMS) took a major step to clarify how it will address the major challenge facing Medicare (and therefore our health care system): transforming an episodic, acute-care dominated, fee-for-service system into one that can meet the challenge of complex chronic care, improving the health of older people while reducing spending.
This is the challenge our new “downstream” grantmaking strategy is designed to address, making CMS’s proposal both very welcome and a high-stakes opportunity to advance our hopes.
In this post I will review some of the specifics of the proposed solution, which is expected to take effect in 2015. The full proposal is available as a PDF on the Office of the Federal Register website—see pages 589-632 (don’t worry, it’s double spaced).You can still provide comment on the changes until Jan. 27 through the online form at regulations.gov or by regular mail. You'll find the mailing address on page 2 of the proposal online. If you want more information, the CMS contact person is Darlene Fleischmann.
However, what I really want to call attention to are the truly radical implications of how this reform might work and the opportunity that the geriatric community still has to get ready, as well as to shape its implementation.
The new tool is a proposed code (and associated payment) for chronic care management, initially unveiled by CMS in July and discussed on Health AGEnda as well as by CMS and HHS leaders in JAMA.
Following a comment period and internal review, last week—on the day before Thanksgiving—CMS quietly unveiled its first decisions in the 2014 Physician Fee Schedule.
At the outset, in overturning years of policy to the contrary, CMS acknowledges that the care management and coordination services needed by Medicare beneficiaries with two or more chronic conditions are NOT adequately reimbursed under the existing evaluation and management codes through which most primary care services are paid. Historically CMS has held that the payments for these services already included the non-face-to-face services of care coordination, such as communicating with other providers and developing a care plan.
Now, they concede that this is not true.
CMS therefore proposes a “Chronic Care Management” benefit that can be offered to beneficiaries with “multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”
Since approximately 50 percent of Medicare beneficiaries have two or more chronic conditions, many of which are significant risk factors for these bad outcomes, I would guess that somewhere between 25 and 50 percent of beneficiaries might legitimately be considered eligible. Because there still will be co-pays, beneficiaries would also be asked to explicitly consent to allow a particular provider to act as their care coordinator and bill CMS for the services.
The chronic care management services would include many of the most prized items from any geriatric wish list, including a patient-centered care plan, a care team, a focus on function, referral and communication with community services, medication review, care transition support, and communication with home-based services.
Care management is defined as:
- Assessment of medical, functional, and psychosocial needs
- System-based approaches to ensure timely receipt of recommended preventive care
- Medication reconciliation with review of adherence, self-management, and interactions
- Creation of patient-centered plan of care in consultation with patient and other key practitioners that is congruent with patient choices and values
- Among many things, plans of care should include community/social services ordered, how services by agencies and specialists will be coordinated, who will be responsible, and how the plan and its delivery will periodically be reviewed.
Specifically the proposal lists:
- 24/7 access to providers to “address a patient’s acute chronic care needs” and these providers would be required at all times to themselves have access to the full electronic medical record.
- Continuity of care with a designated practitioner on the care team who would provide success routine appointments.
- Care transition services, including referrals to other clinicians and post emergency department (ED), hospital, and skilled nursing facility discharge visits, facilitated communication of patient records to other providers across transitions, and the availability of qualified personnel to deliver care transition services in a timely way.
- Coordination with home and community-based clinical service providers required to support psychosocial needs and functional deficits documented in patient records.
- Enhanced access to providers via secure messaging, internet, etc.
While these services in themselves imply a radical transformation of how primary care has typically been organized and delivered (e.g., adding an in-office care team beyond a physician, and a functioning virtual team outside the office, provision of out-of-office services, and use of electronic health records), CMS proposes to be even more demanding in the standards it has suggested as requirements of practices to use the code.
As CMS tactfully puts it, “Not all physicians and nonphysician practitioners who wish to furnish chronic care management services currently have the capability to fully furnish the scope of these services without making additional investments in technology, staff training, and the development and maintenance of systems and processes to furnish these services.”
The standards that are under further consideration include: practices meeting meaningful use standards for electronic health records , having written protocols for care processes, achieving official recognition for patient-centered medical home status, and employing a nurse practitioner or physician assistant in the practice.
This represents a substantial departure for CMS, which up to now has considered all practitioners equivalently skilled and all practices equally capable—a falsehood of which those of us focused on geriatric care have long been painfully aware.
And while one can certainly quibble about which standards are more important than others, the virtues of nurse practitioners versus registered nurses, etc., the fundamental admission is plain: Our current health care system simply does not have the tools and skills to do what is needed to manage chronic conditions in older Americans that are the major drivers of poor outcomes and high-cost services.
So the inclusion of such required standards alone are perhaps the most important point of this proposal and would be a powerful push to the redesign of health care delivery. In fact, I wonder why the proposed standards don’t include requirements such as on-going training in geriatrics and palliative care for both physician and non-physician professionals.
I think that the evidence of improved outcomes due to additional geriatric training is probably somewhat better than the evidence for improved outcomes due to the use of electronic health records. In any event, this is an area where CMS continues to be interested in feedback and comment and that won’t be finalized until the end of 2014.
Overall, the proposed transformation is gargantuan, and clearly implies a lot of work and a lot of infrastructure (both human and electronic). In turn, this implies that the payment for the chronic care benefit should be substantial, especially as it would also take the place of existing payments for supervision of home health services, the new care transitions benefit, and hospice liaison services.
Worryingly, in its final rule on the issue, CMS has decided that the providers can charge for monthly episodes of care as long as there is at least 20 minutes of non-face-to-face care coordination services provided by members of the practice care team in those 30 days. If the payment is then calibrated to only 20 minutes of service in a month, provided largely by non-physicians, one would expect a lower level of payment for the new code.
However, in its final rule, CMS did decide to drop a distinction it had proposed between the initial service period and subsequent service periods, making the very important observation that it was just as important to pay for delivering the care coordination services as it was to pay for planning them.
Getting the payment right is clearly another critical challenge to making this benefit effective. And because this kind of care has been virtually impossible in regular practice due to the lack of appropriate payment in the past, I have a very hard time believing that the regular Relative Value Scale Update Committee (RUC) process (see Revising the RUC Recipe) will be of much use in establishing an appropriate price. This may be another area where specialty geriatric practices and health services research may have an important contribution to make in informing the final, final rule.
This year, as the John A. Hartford Foundation’s new Change AGEnts program gets rolling, one of its focus areas will be working to ensure that “medical homes” and enhanced primary care more generally can meet the needs of older adults.
The opportunity to refine and help implement this proposed Medicare benefit provides an incredible opportunity to bring geriatric expertise to the issue of how primary care is delivered to older Americans, as well as the urgency of a very tight deadline.
P.S. This post represents a milestone: my 200th blog post since we launched Health AGEnda in 2009. My colleagues and I want to thank you for reading and, as always, encourage you to join in the conversation by using the Comment form below.