The concerning payment for care coordination is a step in the right direction.
Dr. Matthew Press, an internist in academic medicine, aptly described how demanding excellent care coordination can be. In the August 13, 2014 edition of the New England Journal of Medicine
, Dr. Press wrote of his work with a patient (Mr. K.) who had recently been diagnosed with a mass 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 (see diagram; also see animation, available with the full text of this article at NEJM.org). 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.”
Dr. Press went on to comment he doesn’t have a full-time practice, but splits his time between teaching and caring for patients, and acknowledged how difficult care coordination can be for a physician practicing medicine full-time.
Many primary care physicians have provided care coordination without compensation, but it’s hoped this policy change by CMS will drive improved outcomes. I should point out that care coordination is an integral part of the patient-centered medical home concept. It’s generally a process used by most organizations that provide care using a team-based concept that is value-based, not based on traditional fee-for–service reimbursement.
There will be challenges. Most physicians are highly ethical, but there’s a potential for abuse and perhaps even fraud. I can imagine a physician hiring a nurse practitioner to do nothing but make telephone calls to elderly patients with several chronic diseases. The CMS requirement for the patient to agree, in writing, beforehand and the patient footing 20% of the bill should drive accountability, but this new program will require oversight. Is the $42 per month proposed by CMS enough compensation to make this worthwhile? I would expect that smaller practices won’t find this feasible at that rate of pay. The requirement that someone from the medical practice be accessible 24/7 may also give physicians some pause.
Even with the inevitable uncertainties of any new program, I think larger, well-organized practices will find this new policy helpful in caring for some of their most complex patients, and I’m hopeful many practices will integrate care coordination into their management of the care of these patients.
Michael L. Taylor, MD, FACP
Chief Medical Officer