More Responsibility for Primary Care
As if primary care physicians (PCPs) didn’t already feel overloaded with responsibilities ranging into increasingly more areas, another head of pressure for them is gaining steam. That’s the growing focus on PCPs to help lower patient readmissions to the hospital.
When the federal government first implemented the Readmissions Reduction Program, requiring the Centers for Medicare & Medicaid Services (CMS) to cut payments to hospitals if they had excessive 30-day readmissions, many hospital executives cried foul. “Why should we be held responsible for what patients do after they’re discharged? That’s between patients and their PCPs.”
That objection has not stopped CMS from imposing heavy penalties on hospitals for what it considers avoidable readmissions for acute myocardial infarction, heart failure, and pneumonia. But the hospitals’ objections have nonetheless made PCPs in office practice more prominent players in lowering these statistics.
The controversial CMS program raises the questions: What exactly can PCPs do to have an impact on hospital readmissions, and will such efforts disrupt their workflow or become a financial burden?
Can PCPs Make a Difference?
There’s little doubt that physicians in ambulatory practice can have a positive effect on readmissions—at least in certain circumstances. One study has found, for instance, that among a large group of patients who underwent surgical repair of an aortic aneurysm, early follow-up with a PCP significantly reduced the risk for readmission, but only if patients had perioperative complications. The same study found that follow-up with a PCP had no impact on a separate group of patients who were hospitalized for ventral hernia repair.
A pilot program that involved four primary care clinics in Oregon has also shown that improved care coordination between inpatient and outpatient clinicians reduced 30-day readmissions from 27% to 7.1%.
Such findings echo a call to action by the American Medical Association in 2013 that outlined what it considers the responsibilities of ambulatory practices to ensure high-quality transitions of care.
The guidelines, outlined in “There and Home Again, Safely,” list several recommendations that many physicians in office practice probably already follow. Among them: Conduct a baseline health assessment before initial admission, encourage patients to self-manage their condition, communicate with all members of the medical team to promote effective medication use, and synchronize the efforts of the entire care team to improve care coordination.
How Will It Affect Your Workload?
Although these guidelines can help reduce needless readmissions, executing them in the real world can take time and resources, both of which are in short supply in physicians’ everyday routine. And some practices are better equipped to deal with them than are others.
“The rate of readmission is highest in the first week or two after discharge,” explained Richard Lopez, MD, chief medical officer of Atrius Health, a large independent physician group in Massachusetts. The single biggest cause of readmission, says Lopez, centers around problems with medication, including incorrect listing of the medication on the discharge instruction, the patient’s inability to obtain the prescription, or taking the medication incorrectly. At Atrius, a nurse or case manager in the ambulatory practice calls the patient within a day of discharge from the hospital and tries to schedule an appointment with the PCP within 7 days of discharge to cover medication problems, review the discharge summary, and the like.
Some larger group practices also bring pharmacists into the mix to help newly discharged patients “make sure they understand how to take their meds, and why…by means of a telephone consult,” explained Megan Clark, practice manager, Research and Insights at The Advisory Board Company.
Unfortunately, many PCPs in smaller private practices can’t afford to hire a case manager or pharmacist to handle this kind of follow-up. Making matters worse, many hospitals don’t notify outpatient clinicians in a timely manner about patient discharges. So the physician may not even know until much later that his or her patient is home from the hospital. And the longer it takes to find out, the less likely the follow-up care will have an impact on readmissions.
Clearly, the kind of care coordination needed to reduce readmission can be a drain on medical practices. And currently, that type of care coordination work is not reimbursed well enough, if at all; thus, there’s less incentive to do it.
There are Medicare billing codes specifically designed to cover postdischarge follow-up office visits, although some thought leaders question whether they’re adequate. CMS says, “Medicare pays for two CPT [Current Procedural Terminology] codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital…” Those codes went into effect in January 2013. In January 2015, code 99490 will also be available to help reimburse physicians for the non–face-to-face time involved in the postdischarge management of patients with chronic conditions.
Robert Newman, MD, medical director of Ghent Family Medicine, part of the East Virginia Medical School Medical Group, believes most physicians don’t resent being asked to do their part in keeping patients out of the hospital because it’s the right thing to do. Having said that, Newman added, “The resentment comes from the fact that we are being asked to do more work without being paid for it. We need more incentives to do this work, maybe make the transitions of care codes pay better.”
Ways You May Be Held Accountable
If you work in ambulatory non-inpatient setting, either as an independent practitioner or an employee of a group practice, how will the push to lower readmissions affect you? That largely depends on whether you are part of a hospital-owned network, and whether you are in a strictly fee-for-service setting or work in some sort of pay-for-performance system.
“If you’re a hospital-employed PCP [working in an ambulatory setting], you may see some mandates from your practice managers,” explains Newman. In contrast, physicians in Dr Newman’s independent group practice are not currently penalized for their readmission rates.
Office-based physicians committed to some sort of pay-for-performance system may also face financial pressures to lower their readmit statistics.
Practices that have contracts with private insurers that offer bundled payments may find they are losing money if their patients’ combined inpatient and outpatient care exceeds certain financial thresholds, for instance.
To help rein in costs, some group practices are now giving physicians report cards that take into account readmission rates. “When doctors and healthcare teams in the outpatient sector start to get rewarded for doing what is needed to prevent 30-day readmissions, then it becomes much easier to make the commitment in time, energy, and resources” says Leonard Fromer, MD, executive director of Group Practice Forum, which advises group practices on how to improve care coordination.
Those rewards, says Fromer, often include a report card arrangement to evaluate physicians’ performance and compensation. Such evaluation protocols can include readmission rates, productivity, and patient satisfaction.
But Fromer emphasizes the need to fairly measure readmission rates. That includes risk stratification that takes into account disease severity and the amount of chronic disease in each doctor’s patient panel. It’s unfair to penalize a clinician for high readmission rates if her patients are much sicker than those of her colleagues.
Turning Obstacles Into Opportunity
If you’re working in a strictly fee-for-service setting and are not owned by a hospital, most experts agree that the Readmissions Reduction Program will have virtually no impact on your bottom line—at least for now. As currently written, the regulations only penalize hospitals.
But many PCPs in private practice see the writing on the wall. Instead of waiting for government and private insurers to force them into a performance-based reimbursement system that does factor in readmission rates, they are forming accountable care organization (ACOs) and similar arrangements that can become more profitable if managed wisely.
A good example is the Palm Beach ACO, a physician-run ACO that saved $22 million in its first year and was able to obtain $11 million in shared savings as part of the Medicare Shared Savings Program. An important component of this physician-controlled ACO included transitional care measures to keep patients out of the hospital. A report from the American Academy of Family Practice pointed out that the ACO “receives as much as $244 for a highly complex transitional care visit…and can bill $173 for consulting a transitional patient within 14 days of hospital discharge if the care is not considered complex.”
Although it’s unlikely that such reimbursement fees alone are going to add $11 million to your bottom line in one year, combining them with all the other strategies, including medication reconciliation, reviewing discharge summaries, and making early follow-up phone calls, can turn the race to lower readmissions into a win/win situation for you and your patients.
- Centers for Medicare & Medicaid Services. Readmissions reduction program. August 4, 2014. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Accessed December 18, 2014.
- Brooke BS, Stone DH, Cronenwell JL, et al. Early primary care follow-up and readmissions after high-risk surgery. JAMA Surg. 2014;149:821-828. http://archsurg.jamanetwork.com/article.aspx?articleid=1883584 Accessed December 18, 2014.
- White B, Carney PA, Flynn J, Marino M, Fields S. Reducing hospital readmissions through primary care transformation. J Fam Pract. 2014;63:67-74.
- American Medical Association. There and home again, safely: 5 responsibilities of ambulatory practices in high quality care transitions. 2013. http://selfmanagementalliance.org/wp-content/uploads/2013/11/There-and-Home-Safely_ambulatory-practices.pdf Accessed December 18, 2014.
- Centers for Medicare & Medicaid Services. Frequently asked questions about billing Medicare for transitional care management services. August 21, 2013. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-tcms.pdf Accessed December 19, 2014.
- Laff M. After one year, physician-run ACO scores big savings bonus. AAFP News. August 11, 2014. http://www.aafp.org/news/practice-professional-issues/20140811palmbeachaco.html Accessed December 22, 2014.