The CMS proposal for the new Medical Home Model demonstration project put me into mathematical gear. I wasn't quite sure if I was reading the proposal with complete accuracy and indicated that in my blog entry. I had an excellent discussion in my comments section by a physician who believes this model will be a great asset to primary care. This physician alleviated my concern about the practice expense RVU being adjusted for the hiring of two new full time RN's or similar.
However, my concerns have not been alleviated with regards to how the RUC values the physician's time in this endeavor. The whole basis of faulty economics is built into the inability of the RVU model as pushed by the RUC to adequately compensate E&M encounters. To do so, under current law would force massive cuts and redistribution in payment rates from less common (relative to E&M) procedural codes which are much more lucrative financially. Since E&M codes are, on a volume basis, far and away the most common billable codes, even small increases in their payment rates result in much larger decreases in less common but higher paid procedure codes. And that's why the battles are so fierce on the specialist controlled RUC committee. Each protecting their financial interest in their society codes.
My understanding now, as it relates to the proposed payment model for the medical home, is that CMS will pay, through the practice expense RVU component, to hire the equivalent of 2 full time clinical specialists, RN or similar to accommodate an estimated 330 hours a month of extra work for 250 patients in a physician's medical home. The anonymous physician indicated that a physician will be paid upwards of $25-$50/month per patient in the new medical home model, more than just the $13 and change in work RVU, that I assumed. Let's use $50 at the upper end. That comes out to $150,000 a year, in excess revenue from CMS for being a medical home to 250 patients.
Now, that may seem like a gold mine, but the expectation is that the work needed to provide service to 250 Medicare patients will require the physician to hire two full time RN's or similar. Maybe some outpatient docs can help me, but the last time I checked, the floor on RN's was about $20 an hour before benefits, before paying health insurance, before paying malpractice, before paying retirement, before paying FICA taxes, before paying for leave and vacation. I would conservatively estimate an RN or equivalent would run near $55,000 a year in total compensation. With two on staff, that would cost you $110,000 a year in extra support staff to run your medical home. And that's conservative.
Now what's left over? $40,000. Well, that might seem like a great chunk of change for the physician to take home. But remember, the physician is being paid to provide comprehensive, coordinated care. Am I to believe that no extra time on the part of the physician will be required in the medical home model? RUC assumes the physician will spend 9.2 minutes a month per patient in a Tier 3 home. That's 460 hours a year. At $40,000, that comes out to $87 an hour, before paying over head. That's like a take home pay of $90,000 a year. Insulting to say the least.
Now, lets assume for the sake of debate, that the doc doesn't spend 9.2 minutes a month extra on each patient. How about 4 minutes a month in doctor time coordinating complex Medicare patients. Four minutes per patient, per month folks. That's one minute a week per patient. Or 200 hours a year, all inclusive. If the doc is making $40,000 in excess payments, that works out to $200 an hour, before overhead. After overhead, that is the equivalent of a $200,000 a year in take home pay for a 40 hour a week outpatient practice.. That's at the high upper limits of current primary care practices. 4 minutes per patient per month is the equivalent of 4 hours a week.
The RUC envisioned 8 hours a week. So I'm assuming one half of the envisioned work, just to break even. It would take a doc spending no more than 4 hours a week managing 250 patients. I can't even look at one chart for less than 5 minutes before making clinical decisions.
I think there is a terribly faulty assumption that the docs involvement with their time will be minimal. The medical home should be a place where the primary care doc can spend MORE time with the patient, spending MORE time in the actual patient encounters. That is where the clinical decisions are made. In the doctor patient encounter. That's where the money is spent. That's where the real savings could be achieved. Through physician ration of services by making sound physician judgements. At the point of service. But that takes time.
- do I increase the B-blocker?
- Do I refer to cardiology? To renal?
- Do I add an ACEi?
- What labs need followed?
- Why are they dizzy?
- Do I need an Echo or a stress test?
- What is their fluid status?
- Do any drug levels need checked?
- Any drug interactions?
- What's the INR?
There are a 1000 questions that can arise during an acute E&M encounter that determines the plan of action going forward. It's no different for hospitalists. Except, I have all day to formulate my plan on all my patients, since they are there the entire time. They aren't gone from the office in 10 minutes. I can think for an hour about what to do with an abnormal lab, whether to consult cardiology, whether to sit on something and just follow it. As a hospitalist, time is on my side, in a big way. The RUC has recommended a model who's E&M encounter is status quo in payment for clinical decision making at a point of care, and diverting funds to nurses and coordinators for the "easy stuff". If I'm a doctor and I have a complicated Medicare patient with 10 medical problems, a newly hired nurse isn't going to decide if they need an echo, if they need lab, if they are experiencing a drug interaction, if they are too dry or too wet. If they have been eating too many potato chips. If they lost their job. The physician is still of vital importance in establishing the care plan. And that happens at the point of patient contact, not in the lunch room at a meeting. The doc, as the expert will be making the decision on what referrals, labs, xrays etc need to be performed at the point of E&M service. Failure to include reprieve from embarrassing payment rates for cognitive medicine will keep the volume mills at status quo. Time to cogitate, to formulate medical plans, to discuss options with patients, to understand their wishes. That takes time for the doc. It will not be solved by a nurse making sure a HgBA1C is up to date, or that the patient is on an aspirin, or that they had their mammogram. Like myself, if I am rushed and don't have the time to cogitate, patients get referred to specialists. It simply would not be fair to the patient for me to give them a 1/2 ass evaluation. That is why a Medical Home that doesn't fix the rate of payment for E&M will not likely offer significant cost savings or quality. In fact, I suspect it will end up costing more money for CMS without significant economic return. I can think of at least 10 occasions a week that I save money by managing conditions myself, because I have the time to do so. A ration of sort based on my sound medical judgement. I just don't see a significant improvement in patient care management until the doc is given more time to cogitate about patient issues. And that will never happen in the current WIN-LOSE fixed pot called RUC/RVU.
10 Outbursts:
Again, I agree. I would like to add that you need to double the RN salary for San Francisco area (and I presume other large metropolitan cities). At the current time, hospital RNs are making more than many Internists and they go home to their families without call or responsibility. I think that blows the medical home model even more than your pathetic figures.
One of the main point of the medical home is to drive physicians to IT. With good IT, it does not require multiple nurses. I have worked with one company on a product that will aggregate data for the MH and give information quickly in the EMR product.
One of my friends who was working on me with this envisioned a practice where you would work the morning and then take an afternoon to do the Chronic Disease management and prevention for the population, communicating via e-mail. If the pay is $150K for doing this, you could possibly afford to do this, couldn't you?
I'm back...
First, you are absolutely correct that the payment for E and M services is too low, and that the PCMH does not address at all the low payment rates for office visits.
Part of the reason for that is that the RVU system makes the ludicrous assumption that a 99213 done by an internist for a complex Medicare patient is the same service as a 99213 done by a dermatologist for a teenager with acne is the same service. A principle difference between these two services is that the first one often requires a substantial amount of non-face-to-face care which, while theoretically included in the 99213, is actually completely uncompensated.
The PCMH payment model leaves the E and M codes unchanged. It has nothing to do with face-to-face care, which some posters may not understand. It is all new money, all for care that is independent of visits. This is the first time ever that medicare has said it will pay for any of this.
It is a big mistake to look at the RUC payment recommendations as a template for how practices will function. This is a payment document, not a description of how the services will be delivered. Medicare is not going to require anybody to follow precisly the times or staffing requirements. When you get the money, you decide how to achieve the goals. You will not be required to show how you spend it, only that you are achieving the goals. You will put some of the money in your pocket, and use the rest to pay for a greatly increased capacity to deal with the needs of your patients.
What the RUC did was an exercise to recommend how much to pay. You need not pay any attention to the times or staffing ratios for any other reason; you aren't going to have to follow them at all.
Rob, I understand where you're coming from. But do you really believe a complicated Medicare patient can be managed with an EHR? I mean really, who's making the the important decisions about care management. The aspirin, the A1c, the mammo, you don't need a $40,000 computer to track that. If that's what a medical home is, you don't need a doctor. In fact, you don't even need an extender. Medicare should just open up EMR centers where patients can go and look to see if all their "quality indicators" have been addressed. I still contend that time with the physician as vastly more important than tracking data. The data is less important for the patient and physician as it is for the government to track and use in their quality schemes and payment rations. I highly doubt any significant cost savings will come from tracking this stuff. If I have 7 minutes with a patient and they have 5 complaints and abnormal lab, I'm much more likely to refer out and order lots of other lab and xrays than I am to spend time and try to figure out what's going on. Whether a patient had their A1c or their aspirin won't mean jack in the big scheme of things, unless the government is trying to make the jump of faith that a A1c and aspirin will prevent the patient from ever coming to your office with a complaint. That's a fantasy land jump of faith.
anon, I think one possibility of what you are saying is that offices already have all the work for a comprehensive care built into their work flow and that primary care offices won't go hiring new folks because the ones there are already doing the work, in an uncompensated manner.
Now, if that's the case, you're looking at a doubling of the salary almost instantly for primary care offices everywhere. That would be a major coup. In fact, offices could double their appointments times, drop half their patients and still break even. Maybe that's the goal. Then you have an access problem for those not fortunate to be in the model.
But then you have to ask your self, where is the cost savings to the system. How will it pay for itself? If in fact nothing more is being done than is already being done. Unless there is a belief that the EMR will somehow be the white knight in all this. And the computer will somehow create health out of illness. Is it a prevention thing? Is the belief that an EMR will prevent illness from ever occurring? Enough to pay $150,000 a year? If that's the case, I say, show me the data.
To answer your question: yes. But the problem is that we probably differ in what "manage" means to us. To me, the idea of management of Medicare patients is that I make sure all of their services are done as they should. So for the majority, this would be prevention for atherosclerotic disease (lipid control, BP goals) and cancer prevention. In a population, this is much better managed by a computer than by paper records. In the more complex patients, it would boil down to managing their specific diseases by the guidelines when possible. The groups that are pushing MH want some consideration for those who fall outside of disease management - those who are terminally ill or chronically noncompliant. The "management" would simply be reviewing it and either say "not applicable" in the case of terminal patients or "offered/refused" in the case of noncompliance.
The government absolutely wants all docs on an EHR. They want them to be measurable in their behavior. They want to compare "good" and "bad" doctors. They want to change the culture of medicine as a place where care is siloed and move it toward a continuum of care. I am not sure what I think about the first part (but I am sure I will be a "good" doctor), but I applaud the idea of the second. The disjointed nature of care is probably the biggest cost liability in healthcare (IMO), and I do know the whole push for EHR with CCHIT, NHIN, and other projects envisions the idea of coordinated care.
Sorry for long-windedness.
Rob, I understand what you're saying. Maybe my view is skewed because I only work with acute care patients who come to the hospital with a complaint. Are the majority of primary care visits from your patients a routine follow up and no acute issues? Or are the majority of patients folks who show up with a complaint. I can understand meeting all the goals for bp, cholesterol, dm, etc. That's what primary care does. That's their job. I don't see that as part of the uncompensated care, nor a goal of a medical home model. It should be done now. I don't see an EMR having any affect on acute care illness in the office. It is still physician time intensive, something the RUC didn't touch in their recommendations. I don't see how that incorporates into a medical home model. I see uncompensated care as picking up the phone and calling the insurance company. Calling the oxygen supplier. Filling out the medical leave forms. Calling the daughter of granny for a 20 minute up date. Discussing DNR. These aren't care related. These are busy work related.
I think we're talking about two different things. How will an EMR help you get preauthorization for protonix? I understand the government's push for EMR. If in fact it was so important, I would suggest that instituting them in specialists practice would be just as, if not more important, to track how often patients get proceduralized and compare this across regional differences. That has nothing to do with the medical home. If the government believes the EMR is the medical home, then limiting the medical home to just primary care would do nothing to reign in costs.
Let's call it what it is, paying primary care to do the uncompensated busy work. If the EMR is so important, it should not be limited to just primary care, it should be in all offices of all specialties. Like I said, an EMR isn't going to pick up the phone and call the patient's insurance company, at least not yet.
If the Medical home is paying for busy work, I can understand that.
These are all different issues.
I see what you are saying. I am focused more on the chronic-care patients who come into my office. This system would not negate acute care reimbursement, it would supplement it. Here is what the ACP said in their statement on the MH:
"a revised reimbursement system should include compensation for: a) the coordination of care both within a given practice and between consultants, ancillary providers and community resources; b) adoption and use of health information technology for quality improvement; c) provision of enhanced communication access such as secure email and telephone consultation; d) remote monitoring of clinical data using technology; and e) pay-for-reporting/pay-for-performance. Examples of other features of a revised reimbursement model to consider include: a) providing enhanced coverage for beneficiaries and reducing co-insurance for patients who select an advanced medical home for their principal care; and b) reducing administrative burdens for physicians and practices (e.g., modification of documentation requirements for coding, elimination of need for advanced beneficiary notices). "
I think the goal is to have someone who can know what goes on in all places - coordinating the care. The patient is going through the system blindly, not knowing what and where they should go. The concept of MH says that they should have a guide in the process. This necessitates information systems, as the accumulation of data from disparate sources is impossible with paper (nearly).
The Institute for Health Improvement has a summary of The Chronic Care Model that focuses on the better management of chronic conditions. This is a key to the MH.
I really don't think the gist of this is to compensate for authroizations, etc. The idea is to get rid of this and instead focus on outcomes rather than the details of care. This is a pie-in-the sky idea, to some extent, but there is good reason it is being pushed by AAP, ACP and AAFP.
Rob, as you state: "This necessitates information systems, as the accumulation of data from disparate sources is impossible with paper (nearly)."
One big problem, when every group in town uses incongruent EMR's that don't talk to each other, it may as well be paper. So how is a PCP supposed to coordinate care any differently in the medical home model than they are now, whether or not they have an EMR.
I deal with this in hospitalist medicine all the time. Offices that have EMR's are worthless to me since I don't have access to it, and they don't "speak" with my hospital's EMR. It might as well be a paper chart.
Thanks for the links. I'll check them out.
The one great thing about the VA is that their EMR is nationwide. When I was in training, I could pull up records from anywhere within the VA system, anywhere in the country. That was my only decent experience there from a work flow point of view.
Happy
This is the reason for the push for CCHIT certification which will force EMR's to adopt standards that will allow communication. It is also the reason for the idea of the National Health Information Network.
FYI, we have offered our hospitalists to get access to information from our EMR at their request (as well as ED physicians) through secure e-mail. It is quite easy with our system. Nobody has shown interest. When it is not paid for, they won't do it.