A detour on the way to the medical home

Last week the Centers for Medicare & Medicaid Services (CMS) published an update on the long-delayed Medicare Medical Home Demonstration. The September announcement from the Department of Health and Human Services of a Multi-Payer Advanced Primary Care Practice Demonstraton initiated by the Obama administration had raised more questions about the future of the medical home project. The explanation from CMS was brief and to the point: “At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot.”

CMS describes the similar pilot as “an independent practitioner-based medical home pilot.” The pending legislation that describes it is the House of Representatives health care reform bill (HR 3200). The two pilots do appear similar in many respects, but one needs to read no further than subsection (a)(4) of Section 1302 “Medical Home Pilot Program” to discover a significant difference between the proposed pilot and its would-be predecessor. Under “Participation of Nurse Practitioners and Physician Assistants,” the bill stipulates that nurse practitioners and physician assistants may lead patient-centered medical homes as long they are acting consistently with state law and other requirements are met.  

Family physicians concerned about turf issues may see this as a setback. The good news is that primary care and medical homes are still the focus of discussion and legislation in Washington, even though the first Medicare medical home demonstration, which many believed would help breathe new life into family medicine, is apparently at death’s door.

Posted at 01:58PM Nov 03, 2009 by Leigh Ann Backer  |  Comments[0]

Medicare's medical home demonstration project: Old news?

A recent press release from the Department of Health and Human Services (HHS) announcing plans for a demonstration project designed around "Advanced Primary Care models" left us, and perhaps many of you, with two big questions: What is the status of the much-anticipated and long-delayed Medicare medical home demonstration project? What is an Advanced Primary Care model? We now have at least partial answers to these questions.

The Medicare medical home demonstration project is at least briefly mentioned in a fact sheet that describes the newer initiative: "CMS will move forward with a separate Medical Home Demonstration required under the Medicare Improvements for Patients and Providers Act (MIPPA) and the Tax Relief & Health Care Act of 2006 (TRHCA)." But the time frame for the project remains unclear. The original schedule called for the Centers for Medicare & Medicaid Services (CMS) to announce in December 2008 the states where the demonstration would be conducted. The application and qualification processes were to have played out this year, and payments to participating practices were to have begun in January 2010. James Coan, a CMS project officer, said in the spring that the eight states have been selected, but CMS is still awaiting approval from the White House Office of Management and Budget to move forward with the project. That approval was first expected nearly a year ago.

The HHS fact sheet says the Advanced Primary Care model that the new project is designed to test is "also known as the patient-centered medical home." The reason for the new term will have to be the subject of a future blog post, but here's what we do know: The project will build on a model being tested in Vermont, where private insurers and the state's Medicaid program are collaborating to develop standards and compensation incentives for primary care physicians. The demonstration project will create opportunities for Medicare to join in similar efforts. Application materials will be developed this fall with the expectation that the demonstration projects will begin in 2010, according to the release. Nancy-Ann DeParle, director of the White House Office of Health Reform, called the project "a jump start on health insurance reform." Given the uncertainty surrounding the Medicare medical home demonstration, you have to wonder whether government health programs are capable of such a thing.

Posted at 02:24PM Oct 02, 2009 by Leigh Ann Backer  |  Comments[0]

CMS makes e-prescribing simple

When was the last time the Centers for Medicare & Medicaid Services (CMS) made anything simple? Good question. Well, now they have published a document called "2009 Electronic Prescribing (E-Prescribing) Incentive Program Made Simple." It's just four pages, three questions, two tables and three steps, two of which you have to repeat a few hundred times. Simple, huh?

All you have to do is bill one of 33 CPT and G codes plus one of another set of three G codes for at least 50 percent of your patients, hope that CMS corrects the problems associated with the Physician Quality Reporting Initiative (PQRI) last year and rake in the incentive payments.

OK. I recognize that, even as simple as that sounds, it may not tempt you. But that doesn't make e-prescribing a bad deal in itself, as Kenneth Adler's article in our current issue argues. If you're not already doing e-prescribing, it's at least worth a look. And once you're up and running with it, you can decide whether you want to simplify your life by going for the Medicare incentive.

Posted at 04:46PM Jan 29, 2009 by Bob Edsall  |  Comments[5]

Medicare beneficiaries can't find doctors. Is that bad news?

I hope no one will call me for piling on if I follow Leigh Ann's entry about the 2007 PQRI mess with another on Medicare woes, but I'm struck by the recent flurry of stories about Medicare beneficiaries having a hard time finding doctors who are accepting new Medicare patients. Monday's Washington Post Story may be the one with the highest profile. It cites the report that probably stimulated most of the coverage:

While statistics are not available for the D.C. region, the Medicare Payment Advisory Commission reported last week that nearly 30 percent of the 2.6 million Medicare beneficiaries seeking a new primary care physician between September 2007 and October 2008 had trouble finding one, up from 25 percent in 2005. To encourage primary care doctors to accept new Medicare patients, the commission recommended to Congress in June that it increase payments to those practitioners by redistributing payments for specialized care.

But the Post story about Northern Virginia has company across the country – for instance in Southern Utah (the Spectrum & Daily News), Oklahoma (The Oklahoman), and as far away as Fairbanks, Alaska (the Daily News - Miner).

Then, of course, there's Massachusetts, where the shortage of primary care physicians willing to take new Medicare patients is just part of the problem. An NPR story highlighted the Mass. mess a week or two ago.

Stories like these are replete with anecdotes of patients calling practice after practice looking fruitlessly for a doctor, getting regular care from the emergency department, and so on, but they also share what seems to be a growing awareness of the underlying problem: that primary care physicians are underpaid, overworked and fed up. In fact, it's hard to avoid the sense that the light is dawning across the country – that people are coming to realize that universal coverage won't solve anything without universal primary care, and that to get more primary care physicians, we may need to work them less, pay them more, and let them do their jobs. Wouldn't that be nice?

Posted at 03:48PM Dec 12, 2008 by Bob Edsall  |  Comments[2]

How to get a 5.1 percent "raise" from Medicare

The Centers for Medicare & Medicaid Services released its 2009 physician fee schedule last week, and there's actually some good news: You could get a 5.1 percent pay boost from Medicare next year. But here's the bad news: You'll have to jump through a few more hoops in order to get it.

The potential 5.1 percent increase has three components:

First, there's a 1.1 percent update to the physician fee schedule, which all physicians will receive. This update was required by the Medicare Improvements for Patients and Providers Act of 2008, which averted a 10.6 percent decrease in physician payments.

Next, there's an incentive payment of 2 percent of your total Medicare allowed charges during 2009 if you use a qualified electronic prescribing (e-prescribing) system to transmit your prescriptions to pharmacies. You will also need to report one of three G codes with your claims to indicate either that you used e-prescribing for all medications prescribed during the visit (code G8443), you did not prescribe any medications during the visit (code G8445), or you did not use e-prescribing because the law prohibits it for the specific type of drug prescribed (such as a controlled substance), the patient requested it or the e-prescribing system was temporarily down (code G8446). If this sounds like too much trouble, note that if you don't switch to e-prescribing, your allowed Medicare charges will be reduced by 1 percent starting in 2012 and by 2 percent starting in 2014, when the incentive payments go away. But don't let that taint your view of e-prescribing. As family physician Ken Adler recently wrote in an article for FPM, "E-prescribing has come of age and is truly a win for everyone – patients, payers, pharmacies and physicians" because of the patient safety and other benefits it offers.

Finally, there's a 2 percent incentive payment if you successfully report measures under the Physician Quality Reporting Initiative (PQRI), which was launched in 2007. For 2009, there are 52 new quality measures to choose from, bringing the total number of measures to 153, but you only have to report on three measures 80 percent of the time. For an overview of how the PQRI works, see Measuring for Medicare: The Physician Quality Reporting Initiative.

If you have any e-prescribing or PQRI tips that you'd like to share with your colleagues, please post your comments below.

Posted at 05:24PM Nov 06, 2008 by Brandi White  |  Comments[2]