Volume Trumps Time, Every Time.

There’s another inherent contradiction in the RUC methodology. On the one hand, if as you suggest that physicians are already providing care management services but not getting paid for it, why bother to go through the RUC machinations? Under this assumption there would be no improvement in savings or quality if physicians are already providing the service.-- e-care management Blog

I agree completely.

A while ago I talked about the new Medical Home Model Demonstration Project being introduced.  I had a compelling series of back and forth comments with what appears to be a fairly knowledgeable physician.  I came back with a separate blog entry with a reinterpretation of the data in the Medical Home Revisited.  I came to the conclusion that doctors could make up to an additional $50/patient/month.  On a 250 patient Medicare panel,  that would work out to $12,500 a month.  Here's what the AMA News is reporting in their June 2nd, edition

Pretty close.  They estimate, for a tier three office an additional $13,500 a month.  Now  that's a lot of money.  In essence,  it would double the salary of primary care overnight, if you are of the camp that believes that Tier 3 offices already exist, carry on all the functions of a medical home, but aren't being paid for it.   The alternative scenario,  calculated by the RUC suggests the hiring of new personnel, care managers and EMR of which they provide this $161,871 to implement the plan.Source: American Medical Association/Specialty Society RVS Update Committee

So here we are.  Two scenarios.  A doctor who qualifies for the tier 3 program, is already carrying out all the duties of a Medical Home,  for free,  will bank in pure profit $161,871.  Or number two.  A doctor who needs to hire staff, initiate an EMR and will bank, maybe 1/5 of that to take home. A $30,000-$40,000 raise.  The question then remains, how much extra time will the physician actually have to spend in this endeavor.  The RUC estimates 9.2 minutes per patient per month.  That's about 40 hours a month. These are all blank estimates by a committee that met by conference call 11 times in two months, and once briefly when the final decision was made.  If the physician is in fact spending time, that time will detract from seeing more patients.  The unknowns are many.
The goal of course will be cost savings.  Expected savings to be obtained by reduced hospitalizations, reduced complications, reduced waste and duplication of testing.  Those that say that physicians offices already provide this service for free,  will say the physician walks away with a doubling of their salary.  Great.  Fantastic for primary care.  It's about time.   But, if you are building the program around the premise of cost savings,  the program will be a pure and utter disaster.  Nothing will change except an increased flow of money.  So stop marketing the program as a quality and cost savings initiative and call it what it is,  a long overdue boost to the uncompensated work load of comprehensive practioners everywhere. 
If the goal is to get comprehensive care offices not already providing all these services for free, to invest in an EMR, to hire care coordinators and nurses to organize the office around a Medical Home Model,  the costs of the program will eat up the vast majority of the increased revenue being offered.  So you are left with a scenario where the duties of the office have increased,  a potential cost savings exists,  but the expense to the office to achieve the cost savings will not significantly improve the financial prospects of the doc himself and for the future prospects of the comprehensive  care field in general.  The doc has little to gain and much to lose in this expensive financial endeavor.  You may possibly (I'm not convinced) see some cost savings, but the financial rewards to the doc will be pretty limited, when looking at the big picture.
Let's stop kidding ourselves.  You can create a 100 different payment schemes with thousands of embedded rules, put a fancy name on it and declare a demonstration project.  Then wait years to test its efficiency.  Or you can scrap the rules called RVU that created the mess.  What cognitive docs need to save money is time.  Time to think.  Time  to manage.  When a patient comes in with "dizziness" and you have 8 minutes to see them,  the social worker and the nurse you hired to gather data and make phone calls ain't gonna do you any good when deciding how to evaluate your patient in front of you.  And until the payment structure moves away from volume, volume trumps time, every time.