Medical Home Summit takes the temperature of the PCMH
Last week, the Fifth Annual Medical Home Summit was held in Philadelphia, attracting more than 300 physicians, practice managers and other industry members to discuss the current state of practices moving to the patient-centered medical home (PCMH) model.
The model is no longer an experiment, with conference co-chair Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, saying that more than 4,600 sites and 8,300 clinicians were recognized as medical homes in 2012 by the National Committee for Quality Assurance (NCQA), up from just 28 sites and 214 clinicians in 2008.
Much of the discussion was on the many paths organizations across the country are taking to become medical homes and use that structure to improve patient care and patient experience and control health care costs.
Here are five key themes that emerged during the four-day conference:
1. Patients and their families are a key resource in designing how your medical home is built and how to measure its success. Several speakers recommended establishing patient advisory panels so you can make sure that how you provide care and outreach services matches what patients actually want. Also, asking patients' families how they evaluate their health care experience is helpful instead of relying on purely clinical data or process information. Said one presenter, "We often ask things they don't care about."
2. Going hand-in-hand with that involvement is the need to make patients more responsible for their own care, presenters said. That doesn't mean giving up your clinical expertise but instead truly making them part of the team and helping them realize they're not just consumers of health care but "experts" on their own health care needs. Presenters said this involves finding ways to give patients a "voice" in their care that they didn't know they had, but it also will require retraining physicians, nurses, and other providers who were likely not taught non-medical collaboration skills in school.
3. Technology is both an accelerant and a damper on the true opportunity of a medical home. Electronic health records (EHRs), with the ability to help physicians parse their patient panel and identify the sickest individuals or those needing better care coordination, could help make medical homes far more targeted and effective in reducing unnecessary care and cost. But several physicians also complained that many EHRs simply aren't flexible enough to support the wide variety of operational and financial quirks physicians can build into their medical homes and that EHRs lack the interoperability to adequately share data between providers. More technology advancement is needed, they said.
4. Medical homes will continue to rely a great deal on non-physician providers. In fact, several speakers said that how doctors include registered nurses, licensed vocational nurses, physician assistants, medical assistants, and a patchwork of "community care teams," "patient navigators," and "pre-visit planners" in their medical homes' operation will determine if their efforts are successful. That's because medical homes are supposed to create efficiency, they said, letting the physician focus on the sickest patients and letting the rest of the team handle the day-to-day care coordination that will ultimately keep patients out of the doctor's office or hospital. For more information on the roles of medical assistants in medical homes, see this recent Family Practice Management article.
One of the meeting's bigger moments was during a presentation by Camden, N.J., physician Jeffrey Brenner, MD, who suggested that health care groups that don't do a better job of coordinating routine care through their physician offices could find themselves upended and put out of business by nurse practitioners doing many of those preventive procedures themselves. In fact, he compared nurses with the advent of Netflix and other "disruptive" market forces that ultimately reshaped entire industries.
5. Everything still hinges on getting paid. As speakers discussed their own practice designs, complexity of patient panels, and relative success in improving patient outcomes, many returned to the question of when commercial payers or their state Medicaid programs might recognize and pay for the medical home approach. The National Academy of State Health Policy saying that 28 states now have some form of PCMH payment, and the consensus was that most major insurance companies are increasing their interest in the potential benefits of the medical home approach and that "shared savings" – where the provider and the insurer split any savings on the cost of care – is an emerging payment model. Presenters said creating payment schemes where physicians aren't in danger of making less than a certain amount per patient because of "shared risk" (although still able to receive bonuses for improved quality) provides the best chance of motivating physicians to form a medical home.
Six things family physicians can be thankful for
Yes, the health care system is inefficient. Yes, it frustrates physicians and patients alike. And, yes, it often rewards the wrong things. But at this time of the year, it seems appropriate to reflect on a few bright spots, particularly for family physicians:
1. A 10-percent, quarterly Medicare bonus for certain primary care services through 2015.
3. A 7-percent pay increase for primary care services via the 2013 Medicare Physician Fee Schedule (assuming, of course, that the 27-percent pay cut due to the SGR is avoided again).
4. More payers offering improved primary care payments, including care-management fees. Wellpoint is one of the latest examples.
6. A delay in ICD-10!
What would you add to the list?
New higher Medicaid rates on the way
Family medicine physicians can look forward to higher reimbursement checks next year when they take care of Medicaid patients.
The Centers for Medicare and Medicaid Services (CMS) on Nov. 1 announced final rules that will require that physicians providing certain primary care services to Medicaid patients get paid at the same rate as they do for treating Medicare patients beginning Jan. 1 and extending to the end of 2014. Medicaid, overseen by the individual states, typically reimburses at a lower rate than the federally operated Medicare program.
The change affects physicians in family medicine, general internal medicine, pediatricians, and related subspecialists, such as pediatric cardiologists. Certain other practitioners, such as nurse practitioners, may also receive the higher reimbursements if working under the direct supervision of a qualifying physician.
The higher payments apply only to evaluation and management services, not specific procedures or diagnostic testing. CMS officials said they will work with the states on the details of implementing the higher payments.
The provision was included in the Affordable Care Act of 2010. The federal government will reimburse states for the difference in cost based on their Medicaid rates as of July 1, 2009.
Other final rules released Thursday included changes in the Value-Based Payment Modifier Program, which will assign bonuses and penalties for physicians based on the quality and cost of care provided. The program will be phased in between 2015 and 2017 with the rules initially applying only to practices with 100 or more eligible professionals.
The original proposal was to start with physician practices of 25 or more professionals. In any event, the government still plans to apply the payment modifiers to all physicians by 2017.
Have you gotten your primary care bonus payment yet?
Most family physicians should be receiving their first quarterly bonus payment from Medicare this month under the Primary Care Incentive Program (PCIP).
The PCIP, established under the Patient Protection and Affordable Care Act, allows primary care physicians to receive bonuses equal to 10 percent of the amount Medicare paid them for primary care services (CPT codes 99201-99215 and 99304-99350) if at least 60 percent of their total Medicare allowed charges are for primary care services. Physicians were not required to take action to receive the bonuses; instead, the Centers for Medicare & Medicaid Services (CMS) has furnished Medicare administrative contractors with a list of eligible providers. (For more information, see "The secret to getting a 10 percent Medicare bonus in 2011.")
The AAFP estimates that 80 percent of family physicians qualify for the bonuses, which are scheduled to continue through 2015.
Some Medicare administrative contractors (MACs), such as Cahaba Government Benefit Administrators, have set up an online PCIP look-up tool to help physicians find out if they are eligible for the bonus program. And at least one MAC, Highmark Medicare
Services, has formally announced that it has begun issuing these payments to
For physicians who qualify, the PCIP payments will arrive on the same check as other Medicare bonuses, such as the health professional shortage area (HPSA) payments, if applicable. They will be labeled "special incentive remittance" to help physicians identify them. Payments will be assigned to the practice unless the physician is listed as a solo physician in CMS' records.
We want to hear from you!
If you've received your bonus, let us know. Was it less than you expected? More? Or, if you're still waiting for your check, we'd like to hear that as well.
The Senate finally passes a temporary SGR fix -- too late to stop the cut
It had to happen sometime: The Senate has finally taken a step toward ending the 21.3 percent cut in Medicare payments that is currently in effect. A short time ago, the Senate majority leader, Sen. Harry Reid (D-Nev.), announced a unanimous consent agreement to raise Medicare payments to physicians by 2.2 percent for a period of six months. The House still has to act for the increase to go into effect, though, and the House isn't scheduled to be in session again until Tuesday. In recent months, the House has tended to be more favorable than the Senate to "SGR fixes" designed to postpone the payment cut, so the news could be good – if a six-month patch can be called good.
That's the end of the good news. The bad news is that the Senate acted just too late to prevent the cut from showing up in physician payments. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare carriers to start paying June claims in the order of submission and at the 21.3 percent lower rate. The axe has finally fallen. Here's the text of the CMS statement on the matter:
The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010.
On May 27, 2010, the Centers for Medicare & Medicaid Services (CMS) initially instructed contractors to hold claims for services paid under the MPFS for the first 10 business days of June. On June 14, CMS extended this hold for an additional three business days (i.e., through June 17, 2010). This hold only affected MPFS claims with dates of service of June 1, 2010 and later.
The CMS today directed contractors to lift the hold and begin processing June 1 and later MPFS claims under the law’s negative update requirement. Held claims will be released and processed on a flow basis, first-in/first-out.
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update. We continue to monitor Congressional actions, and if Congress changes the negative update that is currently in effect, we are prepared to act expeditiously to make the appropriate changes to Medicare claims processing systems.
Keep your fingers crossed. With luck, the House will support the Senate's action and replace the large cut with a small increase as early as Tuesday evening.
Once more, the Senate leaves you with the bill
Or should I say, once more, the Senate leaves you with no bill. On Friday the House of Representatives had voted to keep the axe from falling until January 1, 2012, and had even voted you a raise of 2.2 percent for the rest of 2010 and a further 1 percent for 2011. But the Senate's response was just to go on vacation – Congress's one-week Memorial Day break. So you're once more making 21.3 percent less. Well, technically, you're not getting paid at all, but that's because the Centers for Medicare & Medicaid Services (CMS) have asked carriers to hold payments for 10 days or so to give the Senate time to settle down after vacation and consider the bill. No, it's not déja vu; it's happening again.
But would you want the bill to pass anyway? It wouldn't fix the Sustainable Growth Rate (SGR) formula; it wouldn't even hold things together for very long, and if it did pass, the SGR formula would just kick in again January 1, 2012. Worse, by then it would call for much steeper cuts.
The AAFP, at least, has had almost enough of congressional efforts to avoid decisive action on the SGR. It has laid out criteria by which to judge future patches to the formula. Basically, it will oppose any that expire before the end of 2012 and any that don't include some provision for paying extra for primary care. For now, though, it seems unlikely that Congress will be able to pass any patch that meets the Academy criteria. To get enough votes to pass the bill the House did pass last week, House leadership had to scale it back from a three-year bill that would apparently have met the new AAFP criteria to a two-year bill that does not.
The whole process is beginning to seem like Russian roulette, with the gun pointed at your head. Every time an SGR patch runs out, Congress decides, "What the heck, let's spin the cylinder one more time." I'm guessing that the hammer will come down on an empty chamber this time too – that the Senate and the House will agree on some relatively unpalatable short-term patch that will at least postpone the cut until after the elections. Maybe by then, Congress will have found the courage to make meaningful changes in the whole Medicare payment mess.
The SGR clock is ticking again
Congratulations! Congress, having allowed your Medicare payments to drop by 21.2 percent, finally last Thursday night passed a bill that gave you a raise back up to where you were three weeks ago. Of course, this is just another temporary extension of the status quo intended to give Congress the time it needs to pass a longer temporary extension – one that might take us through October. And that, in turn, will give Congress time to figure out if it has the political courage to face the underlying issue: health care costs that continue to spiral upward.
Despite the fact that the health care reform bill has a couple of provisions that show limited movement in a good direction – shifting money toward primary care and away from more expensive modalities – it's hard to feel optimistic about the prospects. Somehow Congress and political courage just don't seem to fit well in the same sentence. If you could somehow detach yourself from the outcome, the process would be interesting to watch as political theater. Too bad there's no way to practice medicine and detach yourself from the outcome. Taking an employed position certainly won't save you. It's your future they'll be debating.
PCMH: Will it play in Peoria (or Topeka)?
A survey conducted recently by the Kansas Primary Care Physicians Coalition evaluated awareness of and interest in the patient-centered medical home (PCMH) concept among Kansas primary care physicians. Among the findings:
• 63 percent of respondents are interested in redesigning their practices to become qualified as PCMHs.
• Lack of financial incentive and the cost of practice redesign are perceived as the biggest obstacles to PCMH implementation.
• E-prescribing is the PCMH element most commonly in use in respondents’ practices.
Download more results from the Kansas
Academy of Family Physicians (KAFP).
Time's up! You're making 21 percent less
The last grains have trickled out of the Senate's hour glass, and the Medicare patients you see starting tomorrow will bring you 21 percent less. Or they would, if you were being paid for them. Fortunately (?), CMS is directing its regional carriers to hold claims for 10 days, so (with luck and less sand in the gears of the Senate) you may eventually get paid for tomorrow's work at the same rate you earned yesterday.
Medicare payments: Time is about to run out ... again
With about 60 hours left, it looks as though we'll get to see our countdown clock hit zero, unleashing (sort of) the much-discussed 21 percent cut in Medicare payments. At least, that's the word from the AAFP Washington office: "The Senate did not pass a bill that would have extended the SGR [sustainable growth rate] payment rate for physicians until April 30 prior to leaving for a 2-week recess. ... The bill was ready for passage under standard unanimous consent procedures, but Senator Tom Coburn (R-OK) objected because the bill was not completely paid for. As a result, the 21-percent reduction in physician payments will go into effect April 1."
Again, however, CMS has told carriers to hold claims for 10 business days:
Information Regarding the Holding of April Claims for Services
Paid Under the 2010 Medicare Physician Fee Schedule (3-26-2010)
The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.
CMS believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.
Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.
The AAFP Washington update goes on to say that negotiations between the two sides will continue during the recess and it is likely that the bill will proceed quickly through the Senate when they return April 12.
The health care reform bill: What's in it for doctors?
Last night, the House of Representatives voted 219 to 212 to approve the health care reform legislation passed by the Senate in late December. Thirty-four Democrats joined Republicans, who were unanimous in voting against the bill. The President is expected to sign the bill into law tomorrow. The House also adopted a package of “fixes” to the bill, which will now go to the Senate.
To obtain the last few votes needed to pass the bill, the White House promised anti-abortion Democratics that it would issue an executive order ensuring that federal funds will not be used for abortions.
The bill is expected to provide coverage to 32 million uninsured Americans, leaving 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.
The bill is estimated to cost $940 billion over 10 years but would reduce the deficit by $143 billion during that same time frame, according to the Congressional Budget Office. The savings are projected to come from Medicare reforms and from new taxes and fees, including a tax on high-cost (or “Cadillac”) health plans and increased taxes on individuals making more than $200,000 per year or couples making more than $250,000.
Although “Washington may live and die by the pronouncements of the Congressional Budget Office,” wrote pollsters Doug Schoen and Scott Rasmussen in The Wall Street Journal, “81 percent of voters say it’s likely the plan will end up costing more than projected.” The Cato Institute estimates that the bill will cost nearly $3 trillion.
How will the bill affect doctors?
The bill establishes a 10-percent Medicare bonus for many primary care physicians (those whose Medicare charges for office, nursing
facility and home visits comprise at least 60 percent of their total
Medicare charges) for the next five years; increases Medicaid
payments for primary care physicians to 100 percent of Medicare payment
levels for 2013 and 2014; and increases funding for primary care scholarships, loan repayment programs, residency programs, the
National Health Service Corps and community health
centers. Whether these measures will succeed in reversing the shortage of primary care physicians, which will become increasingly critical as newly
insured patients seek care, remains to be seen.
The bill also establishes multiple pilot projects to test payment reform in federal health programs such as moving from payment based on quantity of services to payment based on quality of services, financially rewarding physicians who make their offices “medical homes” for high-need beneficiaries, and establishing “accountable care organizations” that allow providers who voluntarily meet quality standards to share in the cost savings they achieve for the Medicare program.
The bill does not repeal the Medicare sustainable growth rate (SGR) formula or provide comprehensive tort reform.
How will the bill affect patients?
The bill would almost immediately provide the following:
- Patients who become ill cannot be dropped by their health insurer.
- Insurers must provide free preventive care.
- Lifetime benefits cannot be capped.
- For children under age 18, insurance companies cannot deny coverage for pre-existing conditions.
- Young adults can remain covered on their parents’ insurance until age 26.
- Small businesses can claim tax credits to help purchase health insurance for their employees.
Other changes won’t go into effect for several years, such as the following:
- Americans will be required to have health insurance or pay a fine.
- Insurance companies will not be able to deny coverage for pre-existing conditions for adults.
- Medicaid will be expanded to cover an estimated 16 million people.
- Low- and middle-income Americans will be eligible for subsidies to purchase private health insurance – a cost of $938 billion over 10 years.
- Employers with more than 50 employees will be required to offer health care coverage or pay a fine.
- States would establish health insurance exchanges to help consumers without health care coverage and small businesses shop for insurance meeting federal standards.
For a timeline of key changes, see this Washington Post article.
Senator Bunning stops strangling the Senate -- and your Medicare payments
You can breathe easy now – or at least a little easier. As today's update from the AAFP Washington office has it:
Last night, the Senate approved the House-passed bill that extends unemployment benefits, COBRA, the sustainable growth rate for Medicare payments (SGR) and other payment and benefit provisions. The bill funds Medicare payments to physicians at the current rate until March 31. The President immediately signed the bill.
Meanwhile, the Senate is working on another bill that would extend these same benefits for several more months. In the case of the SGR, payments would be extended to October 1 of this year. This bill will likely pass the Senate later this week or early next and would likely be approved quickly in the House. Most Senators who voted for the legislation cited the difficulties created for the unemployed, but they also heard from a large number of physicians and that made a significant difference in their sense of urgency.
So ... the execution has been stayed for at least a month. But the clock is still ticking.
Medicare cuts: The Senate leaves you with the bill
Monday is March 1. That's when Medicare payment rates will drop by 21 percent unless Congress does something. And the Senate won't do anything until Tuesday at the earliest. What does that mean? The (informal) word from the Centers for Medicare & Medicaid Services is that "the bottom line is that there will be a 10 day hold and hopefully by that time we will have a statutory fix." So physicians should submit claims as usual.
The way things stand on the Hill is this, according to the AAFP's Washington office:
Yesterday afternoon, the House passed a bill that contains an extension of the SGR [sustainable growth rate] until March 31. The Senate Majority Whip, Sen. Dick Durbin (D-IL) attempted several times to pass the bill with the unanimous consent of the Senate, but each time Sen. Bunning (R-KY) objected because he wanted to have a vote on his amendment to have the bill paid for with TARP [Troubled Asset Relief Fund] money. Later last night, Sen. Bob Corker (R-TN) joined Sen. Bunning in objecting because he felt that Sen. Bunning was not given sufficient notice that the bill would be taken up. The problem with Sen. Bunning's demand for a vote on his amendment is that the Senate has no scheduled roll call votes until next Tuesday.
The Senate has adjourned for the weekend and will not return for votes until Tuesday noon. Past performance would suggest that the Senate will somehow untangle its feet and prevent the 21 percent cuts for a while at least, even though belatedly. On the other hand, the current state of party politics suggests that past performance may not be an indicator of future results. This might be a good time to e-mail your senators and remind them of the number of lives they're playing with.
And since I imagine you're probably as tired as I am of reports that Congress continues to do nothing, we'll hold off on further updates until something really happens.
More on Medicare cuts: The axe is still poised to strike
An update from the AAFP Washington office to yesterday's post on the impending Medicare physician payment cut: "Yesterday, Senate Majority Leader Harry Reid (D-NV) proposed a one-month extension of the current physician payment rate and asked unanimous consent from the Senate to approve the measure and send it to the House. However, Senator Bunning (R-KY) objected on behalf of Senate Republicans because the bill (which cost about $1 billion) was not fully paid for. Senator Reid is holding the Senate in session today (although no votes will be taken or decisions made during the President's Health Summit) and tomorrow, and will try again to get unanimous consent before they leave for the weekend. The likely compromise would be a two-week extension that is fully paid for."
Evidently, even putting off until next month what you don't want to deal with today is hard for Congress. Three days remain before the threatened 21 percent cut goes into effect. Stay tuned.
Medicare cuts: A (short) stay of execution?
Counting the days until the threatened 21 percent cut in Medicare payment rates kicks in on Feb. 28? Good news (maybe)! Word from the AAFP's Washington office is that the Senate is prepared to approve a two-week suspension of the cuts -- by unanimous consent -- with the House following suit today or tomorrow morning.
Why only two weeks? It seems likely they need more time to figure out how to pay for a few years' postponement of the day of reckoning -- the day when they, or someone with enough political courage, can actually clean up the mess instead of just shifting the problem from their shoulders back to the shoulders of the physicians who have been carrying it for the past several years. Stay tuned to this blog or FPM's Getting Paid blog for more as the saga continues.