Wednesday, November 25, 2015

Here’s a way for primary care doctors to earn a lot more. (If only they would use it)

The fact that primary care is undervalued by Medicare and other payers has been long-understood to be driving the precipitous decline in the numbers of new physicians choosing  primary care internal medicine or family practice, and a growing exodus of established primary care physicians.  Efforts to address this undervaluation have traditionally been to (1) bump up the payments (relative value units) for the office visit codes traditionally billed by primary care physicians, (2) explicitly fund, usually on a temporary basis,  higher payments  for primary care that do not require offsets from others, like was the case with the two-year Medicaid primary care pay parity program, which expired on January 1 of last year, and the five year 10% Medicare primary care bonus program, which is set to expire at the end of this year if Congress doesn’t continue it, (3) offer higher payments contingent on primary care physicians meeting performance measures (pay-for-performance), and/or (4) develop  and promote alternative payments models, like Patient-Centered Medical Homes and Accountable Care Organizations, which offer higher payments in delivery models that require more accountability and risk for quality outcomes and savings.

Each of these approaches are important, and can potentially make a big difference, but each also has its  limitations.  Under Medicare’s “budget neutrality” rules, bumping up the RVUs for office visits results in across-the-board cuts in all RVUs, which intensifies resistance by other specialties.  (Think of it like a pie: a bigger slice for primary care results in a smaller slice for everyone else) . And even the primary care services that are supposed to benefit from the bump end up having to absorb part of the budget-neutrality adjustment. And, because office visits are the most frequently billed services, even a small bump up can result in large across-the-board budget neutrality offsets.  Programs to temporarily fund increased payments for primary care are all well and good, but because they are expensive, they also tend to be time-limited, depending on the willingness of Congress to keep open the funding spigot going past their expiration date.  (Good luck with that!).  Pay-for-performance  programs can potentially increase payments to some primary care physicians but they are a hassle, usually include both penalties and rewards, require a lot of physicians to perform poorly in order for the better performing physicians to get more (another variation of budget neutrality), and physicians don’t have a lot of confidence in the measures being applied.  New payment models may ultimately prove to be the best option to systematically improve payment for primary care,  but there is an uncertain track record with them, and the investment in the practice that is required makes for an uncertain and uneasy cost-benefit for primary care physicians.

What if I told you there was another way, already available to primary care physicians, to potentially earn tens of thousands of dollars more from Medicare and other payers, while improving patient care?  That is already built into Medicare’s budget neutrality adjustments, so there isn’t any resistance from other specialties? That doesn’t tie pay to performance measures?  That isn’t time-limited and temporary, that doesn’t depend on Congress’s “generosity”?  That is available within the traditional fee-for-service payment system, not linked to alternative payment models?

What if I told you that there is another way, one that takes a page out of the surgeons’ book?  One of the way that surgical specialties have been able to earn higher payments is to constantly create new CPT codes and RVUs for their services, slicing and dicing what they do (pun intended) to create more billable opportunities.  Why can’t primary care do the same, creating more codes and RVUs (and with them, more billable revenue opportunities), instead of being stuck with the same old 10 codes for office visits for new and established patients?

Well, this is exactly what has happened over the past few years in primary care.  Largely because of ACP advocacy, Medicare has approved at least 7 new codes that create very substantial billable revenue opportunity for primary care physicians.  Practices that bill for all of them can potentially increase their revenue by six figures, or more.  (One company has developed a spreadsheet that physicians can use to estimate the potential revenue gains, as well as costs associates with the codes).

What are the new codes?  Medicare’s wellness examination, which in 2016 will pay $172.69 for an initial visit, and $116.80 for a subsequent one. Transitions of care management, 14 day discharge, pays $164.81;  7 day discharge pays $232.52.  Chronic care management,  20 minutes, pays $40.84.  And, brand new, for the first time starting on January 1, Medicare will pay $85.99 for 30 minutes of advance care planning!  (These payment amounts are before application of Medicare’s geographic adjustments, and apply to services provided in a non-facility setting).

ACP’s regulatory affairs department has prepared a nice spreadsheet that shows the available payments for these services in both the non-facility and facility settings.

Yet many primary care physicians are not routinely billing for these codes, leaving tens of thousands of dollars at the door.  Many say that the documentation requirements are too much, or they might have to hire more staff, so it’s not worth the effort. There is no question that Medicare could make it easier and simpler for physicians to document these services, as ACP has recommended.

At the same time, though, I expect a cost-benefit analysis would show that many primary care physicians and their practices would come out way ahead if they began to bill for these codes, while improving patient care in the process—a real win-win.

So how about it, primary care doctors?  Isn’t it time for you to consider taking advantage of the new codes and revenue opportunities available to you, even as ACP and others continue to advocate for more fundamental reforms to improve payment for primary care?

Today’s questions:  Do you bill for these new codes?  Why or why not?


Brad F said...

I have written recently on this very topic. I am not at all optimistic:


Jay Larson MD said...

The documentation requirements are very burdensome for transitions in care and chronic care codes. Also to be able use the chronic care codes, all the physicians in a call group has to have access to the patient’s EHR, which is a problem if the call group consists of physicians from different practices (typically seen in smaller communities). $116 for subsequent wellness exam is peanuts for what has to be covered during the evaluation. The problem with all these codes is that they primarily apply only to Medicare and not all commercial insurances. When the 10% bonus to primary care physicians came into effect, not one of our commercial insurances did the same thing.

For years the ACP has commented that primary care is undervalued. Why not fix the problem at its source, the RVU system. The ACP missed the opportunity to fix this years ago when the RVUs for new procedures took over the health care system. They still have not worked at the problem at the source. When is someone going to finally figure out that the formula for the RVU system is flawed? Everyone knew that the SGR formula was flawed and the ACP fought this for years before it was finally repealed. For primary care to finally be valued, the RVU system has to change. I have no sympathy for proceduralists to lose income, they have been running high on the gravy train for decades. We are hitting the ceiling for increasing healthcare costs, so if the only way primary care providers could make more money is at the expense of proceduralists, so be it. Let the subspecialty societies whine, they are much smaller than the ACP. With the exception of researchers and those is academics, every other ACP member would benefit from increased value of E and M codes and decreased value of procedure codes.

General outpatient internal medicine is going extinct. Do something about it. Fix the flawed RVU system.

Harrison said...

I agree that there are codes out there that help primary care but they are not simple to use.
The stipulations for the transition codes include a phone call within 48 hours after the discharge. That means coordination with local hospitalist groups.
We all know how challenging that can be.

The chronic care code involves a couple of things.
We have to have patients sign an ABN, and so they accept the possibility of getting charged...they hate to do that.
We also have to document time with every patient contact. Most of us don't have a culture of having MA's document phone call times to get up to the 20 min of contact.
And we probably don't have 20 min of contact each month with most of our patients.
There aren't that many minutes in most months....

The wellness visits are actually pretty easy to use and that has been good.
My most frustrating thing with those is that one of our local gyn groups thinks they can use it and when they do, we can't.
Of course they don't document appropriately, and as far as I know they have not been audited or fined for it....

One thing that is fairly easy to use and pays something but not a lot is the oversight of Home Health care plan codes.
This one really is simple.
We get paid for simply signing what we are already asked to sign.
If we keep a copy of what we sign, we can send in a bill.
That is worth $200 to $400 per physician per month.
Of course you do have to train MA's to submit the codes, or remember to do so yourself. But that isn't too hard.

There is something to the RVU rates though.
Why is it that other specialties over the years got more money just by bumping up the RVU's, but primary care has to jump through hoops with every potential increase?

Why not bump up primary care RVU's?
Why not more primary care representation on the RUC?

For the forseeable future, even with new payment schemes, fee for service will be dominant. And in that system, RVU rates mean a lot.


Jay Larson MD said...

There are no specific primary care CPT codes. AAFP tried to get them established but failed. Our main codes are the typical office visit codes that all physicians use. If the RVU for OV codes went up, it will go up for all physicians. Insurance companies would just drop the conversion factor and it would be a wash. The only way to meaningfully increase OV codes would be to increase the RVU for OV but also drop the RVU for procedures. Insurance companies don't care where their money goes, just how many RVU's they have to pay for each year.

From the AMA website: The RVU is divided into three components: physician work, practice expense and professional liability insurance. The physician work component accounts, on average, for 48 percent of the total relative value for each service. The factors used to determine physician work include the time it takes to perform the service; the technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient. The physician work relative values are updated each year to account for changes in medical practice.

The RUC updates RVUs. This is composed of 24 specialties and subspecialties. There is a primary care spot on the RUC, but it is still dominated by surgery and surgical subspecialties. 14 spots on the RUC are held by procedure based specialties. Internal medicine and internal medicine subspecialties is under represented (only 5 spots). Surgery and surgical subspecialists account for 10 spots. Because of this RUC composition, procedures are heavily weighted.

Even though the RUC is supposed to update the RVU's, they have not taken in account all the work that a primary care provider does nor time consumption by EHRs.

The ACP could advocate for adding more IM subspecialties to the RUV. Request an update to E and M codes used by internists. Advocate for primary care CPT codes. I much rather have them send a 10 page letter to the RUC outlining the importance of internal medicine rather than sending it to CMS. It is easier to convince 30 people to change the RVU than it is to convince 500 politicians to change something in Medicare.

I know that the ACP advocates for medical homes, but they are very expensive and not always well reimbursed. I just came across a study that found to be NCQA certified, it would cost $100,000 per physician per year to maintain certification. I am a level 2 NCQA medical home and only gets an additional $10,000 per year from only 1 insurance company. Plus the insurance company want us to report on dozens of measures for each patient, hardly worth the effort.

southern doc said...

Paying internists at a rate of $85/30 minutes, with 60% overhead, comes out to a yearly income of $70,000.

Problem solved.

Thanks, ACP! You're doing a great job!

southern doc said...

Oops, miscalculated above:

Make that 140,000/year, at 40 hours patient care, 50 weeks per year.

The point is that valuing internists' time at 85/half hour is further debasing the work we do - it's making things worse, not better. Pays a lot more to see three snotty noses in that time.

But it gets a nice big exclamation point from the truly clueless ACP!

DrJHO7 said...

I agree that the ridiculous documentation requirements for the undervalued chronic care management codes make them not worth documenting or billing for. Transitional care management codes are worth it if you're lucky to know when the patient is (not 'was')discharged, so they are a small uptick. The wellness exam codes fail to significantly impact cash flow because not all of the patients need these visits, and when we do schedule them, the patients invariably have problems that need to be dealt with those days, so you bill E&M with a modifier along with the wellness exam, and medicare denies the claim, then it takes resubmissions with letters of explanation to maybe get it paid for. Very discouraging.

Jay is correct in saying that the RVU system is flawed in accounting for the work of taking care of patients in primary care medicine, which is complex and time consuming. The bulk and breadth of the work we actually do, both in the exam room and apart from the patient from 7 am to 11 pm is insufficiently reimbursed by medicare, and the private insurers are worse, due to their greed.
I don't need 30 minutes to do advance care planning, but I do need 10, and when I use it, it comes at the expense of something else in the 30 minute visit, or makes me run further behind in my schedule.

I am starting to believe that having a scribe in the exam room to take care of most of the documentation is the only way to free up more time with the patient and decrease the perfunctory 2 hours per night with the laptop to complete it, but I don't really want them there and neither do most of the patients I've asked.
I do believe that practices who institute an annual retainer fee for their patients will be more likely to survive going forward. Not the $1500/year+ fees that are charged by concierge practices, but something in the $200's/year/patient range for most of the patients except Medicaid and lower income folks. Insurer contracts would need to be amended to permit this. It won't be popular at 1st, but they'll get used to it if they value their medical practice. They already spend that per month on their cell phone bills.

It's not ACP's job to fix the mess that primary care medicine is in. It's the physician's job (that would be us) to fix it. ACP can help, though. We need their advocacy and their expertise. The staff I know at ACP are expert, hard working, caring, intelligent and competent professionals, and the physicians from all over the country (world) who put in many hours of time/hard work/thoughtful input with ACP are inspiring and impactful. To say that they are clueless is, well...clueless.

Jay Larson MD said...

Individual physicians can’t fix our healthcare system, that is what physician organizations are for. A much larger voice. When the ASIM joined the ACP, the ACP assumed the responsibility to advocate for internal medicine. Even the ACP’s president has commented that half of its advocacy is for patients and the other half is for internal medicine. If the ACP does not advocate for internal medicine, then no one will. Other medical societies are more than willing to take away from internal medicine for their own benefit.
One way to look at advocacy effectiveness is to look at outcomes. Currently half of internists are burned out (top third amongst physician specialties), few internal medicine residents are choosing outpatient general medicine as a career (compared to 50% when I completed residency in 1990), internists are on the low end of the reimbursement scale compared to other physicians, administrative burdens are at an all-time high, and general medicine is very much undervalued. What is going to happen to ACP membership if reimbursement stays flat for another decade and administrative burdens continue to escalate so that physicians are unwilling or unable to pay for membership? What is ACP membership going to look like in 20-30 years once all the current internists retire and there is no one else to replace them?
The ACP is the second largest physician organization, surely internal medicine should be in a much better state than what it is now. Everyone strives for the triple aim. Well there is nothing better to accomplish this than a well-trained internist with enough time to evaluate, think and act. Currently internists don’t have that time because of low reimbursement (forcing internists to see more patients in a shorter period of time) and administrative hassles. What would the health of this country look like if we had twice as many internists who had an extra 15 minutes per office visit?
ACP advocacy has focused a lot of time and effort on Medicare, but that only affects a portion of an internist’s practice. Focus on the RVU system so that it impacts all insurance carriers. The biggest voting block on the RUC are surgeons. Their views of office E and M’s are one dimensional from their own experience…pre-operative assessment, post-operative management. The last time they saw what an internist does was in medical school and that was probably just inpatient care. I think all the surgeons on the RUC should shadow a busy internist for a week to get a much better sense of office visits for chronic care management can be, including all the administrative stuff. Really, should surgeons be the ones determining RVU work values for internists?
Internal medicine has been a very rewarding (excluding financial) career for me, I just don’t like seeing it go down in flames. Individually we cannot fix the system, but collectively we can as members of a physician organization called the ACP.

Dbkav8 said...

A plumber receives $406 for 30 minutes to rotor root a sink, 25-40 % of new physicians are depressed and the ACP suggests we play games with codes.. Fact is we are not valued by the populace unless they need us and most don't. I have watched these musings for a half a century. I have enjoyed myself and still do but do not expect remuneration . Everyone knows you should not expect Congress to care for anyone but themselves. If they were paid for productivity, there would be funding for the food stamp program.
D B Kessler,MD, FACP

ryan said...

I have had the billing department reject transition of care codes because I discharge the patient myself and went to see them in the nursing home the next day, and fully documented that. They claimed I ships have made a phone call to say I was coming down the hall and also documented that.

Anonymous said...

New payment models may ultimately prove to be the best option to systematically improve payment for primary care, but there is an uncertain track record with them, and the investment in the practice that is required makes for an uncertain and uneasy cost-benefit for primary care physicians. stdcheck coupon

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