A Hospitalist's Perspective
After a few days of a low-grade fever and night sweats, 68-year-old Jack, aretiree living in a rural community in Washington State, decided to pay a visitto his local primary care physician. His physical exam was normal, and Jack went home. His symptoms persisted, however, and Jack returned to his doctor. This time, labs were drawn. The lab results suggested lymphoma.
Because it was the Friday before the 4th of July weekend, Jack’s doctor recommended that Jack make the 90-minute trip to the nearest major hospital for further evaluation.
At the tertiary care center ER, the labs were repeated with consistent results, leading to a presumed diagnosis of lymphoma. After being notified of the results, the on-call oncologist recommended an excision lymph node biopsy and requested that Jack follow up with him after the results came back.
TIME FOR A CARE PLAN
When the hospitalist service received the ER physician’s admission request for Jack, they questioned why it was even necessary for Jack to have come to the tertiary care center since the services he needed were all available in his rural community. The primary care physician explained that he felt the work-up would have been faster in the tertiary care center because of the delays that the long holiday weekend could cause.
The hospitalist contacted the on-call general surgeon at the tertiary care center who reviewed the case and determined that the biopsy wasn’t really an emergency, especially given the scarce resources caused by the holiday.
So would Jack stay in the hospital, far away from his home, for the next three days? A second nighttime on-call oncologist was consulted who also agreed that there was no need for Jack to stay in the hospital. The oncologist also suggested that the biopsy could be done as an outpatient procedure in Jack’s hometown.
After hearing back from the second oncologist, the hospitalist called another on-call oncologist, this one in Jack’s hometown. The two physicians agreed that Jack could go home and be seen in the local oncology clinic that Monday. All Jack would have to do was call the office on Monday morning to request an appointment. Armed with a plan, the family headed home late Friday evening.
On Monday morning, when Jack called the oncology clinic, nobody knew who he was. The oncologist they had spoken with on Friday was working at a different clinic, and Jack couldn’t reach him. Unaware of his story, the clinic staff informed Jack that he wouldn’t be seen for a few weeks.
Frustrated, Jack and his wife returned to the tertiary care center emergency room Monday afternoon. The blood work was again repeated, and admission was again requested. After a different hospitalist spoke with a different on-call surgeon, Jack was admitted, the lymph node biopsy was performed, and Jack was discharged to his home on Tuesday.
Both oncologists, the one at the tertiary carecenter and the one at the rural clinic, received the biopsy results. Jack has since received his care at the oncology clinic in his local community.
FRAGMENTED CARE BRINGS UNINTENDED CONSEQUENCES
This case is an example of our fragmented care model and the unintended consequences of the way our current health care system has evolved over time.
In all fairness, it cannot be said that things would have been better if the roles were different, if a rural physician was trying to coordinate care for a patient at a tertiary care center, or if the patient was trying to navigate the system himself. Perhaps it would be even more dysfunctional in one of these other scenarios.
The following physicians were directly or indirectly involved in the care: one primary care physician, two emergency medicine physicians, two hospitalists, three oncologists and two general surgeons, and one anesthesiologist. But the patient only needed the primary care physician, one oncologist, one surgeon, and one anesthesiologist. The preliminary diagnosis was already known. In an ideal world, a single phone call from the primary care physician to the local oncologist could have arranged for Jack to be seen in a timely fashion and formulate a treatment plan, including the biopsy.
One can imagine the cost of care for the patient who went through two ER visits and two hospitalizations for what could have been an outpatient procedure and an office visit, both handled locally.
Stories like these are not isolated examples. The complexities of care only increase with the number of chronic conditions our patients develop over time.
COORDINATING THE CARE
It is not always easy to coordinate care for patients with simple or complex needs. Primary care physicians spend countless hours answering phone calls and MyChart e-mails, reviewing test results and notifying patients, refilling prescriptions, filling out FMLA paperwork, calling insurance companies for pre-authorization on medications and imaging, and so on. This is in addition to 15–20 minute encounters that include seeing patients, applying active listening and other communication skills, gathering history, performing a thorough physical examination, making recommendations, using a health coach approach for lifestyle changes, writing prescriptions, and of course, documenting everything in an electronic health record by the end of the day.
This patient example demonstrates that care coordination is an important aspect of the healthcare delivery for organizations that want to achieve the Triple Aim (quality of care and positive patient experience at lower cost). It will help our patients get the right care at the right time in the right setting, ultimately reducing the cost of care. Until now, this care coordination has been an important aspect of care that has gone unpaid.
INCENTIVIZING CARE COORDINATION
“Healthcare is changing, and part of delivery system reform is recognizing this and making sure payment systems account for these changes,” says the Principal Deputy Administrator at the Centers for Medicare & Medicaid Services (CMS), Jonathan Blum. He adds, “We believe that successful efforts to improve chronic care management for these patients could improve the quality of care while simultaneously decreasing costs, through reductions in hospitalizations, use of postacute care services, and emergency department visits.”
Starting January 2015, the CMS will pay primary care providers $42.60 per month per qualifying patient for care coordination management (CPT code 99490), provided certain requirements are met. The cornerstone of this service is a requirement to provide 20 minutes of nonface-to-face care coordination services to the enrolled patients. The actual services may be provided by licensed social workers, nurses, medical assistants, certified nursing assistants, and other licensed providers under the supervision of the billing provider.
Additional criteria is that the patient must have two or more chronic conditions expected to last for at least 12 months or to result in death (CMS has not identified specific chronic conditions for this rule, but rather provided a broad definition to be interpreted by the physician). The provider must also obtain the patient’s written consent to be included in this care coordination program, for which the patient is also required to pay a nominal monthly co-pay.
The providers must maintain an electronic health record and a care coordination plan based on each enrolled patient’s needs. CMS has specified requirements of this care coordination plan. This plan must be accessible to all members of the care team. The providers must follow up with beneficiaries after ER visits and provide transitional care management after a discharge from an acute care facility.
How will compensation for coordination change scenarios like Jack experienced? When providers realize they will be paid for the work of coordination, more will begin to see this as a responsibility they can embrace as a part of the care they give patients, and their clinics may provide the structure and systems to do so. In Jack’s specific case, the first physician he saw—in his local town—might have more readily taken on the task of coordinating a local effort.
Whether commercial payors will follow suit and also pay for care coordination remains to be seen; however, the fact that CMS now pays for it may make it more likely. It is a pivotal step to see the payers recognize coordination as an important pillar of care that increases efficiencies and reduces costs and reimburse healthcare professionals for this effort.