While I consider myself well read and I work hard to remain connected to and aware of changes happening in medicine, I have only recently become knowledgeable about a new program being rolled out by CMS (Centers for Medicare and Medicaid Services) on January 1, 2015 that may affect a large number of Medicare patients going forward. I also can say that many physicians, and would bet that many patients too, are unaware of this program or how it will actually work.
I first heard about Medicare’s Chronic Care Management (CCM) payment program this past September from a colleague who is a very busy primary care physician with a large patient panel, who believes the program can help improve care for people with chronic health problems, but has concerns about the details. A November 27, 2014 New England Journal of Medicine “Perspective” article by Edwards and Landon summarizes the program nicely, but raises serious questions about implementation, which I echo and hope to explain better to you. The new program is rolling out in a matter of weeks, and there has been hardly any communication from CMS to the public on what the program is, how it works, or why it may be valuable. There is also the 20% cost sharing problem, more on that below.
Let me briefly discuss what the new CCM is. Medicare is the Federal Government program that provides health care to those over 65, and the disabled. The person covered under Medicare is responsible for paying 20% of the allowable charge after Medicare pays the first 80%, either by paying cash or through co-insurance. What this CCM program does is make a new payment to doctors for chronic care management which covers the cost of care that does not involve actual face to face time. This is new because traditional Medicare does not cover services where both the patient and medical doctor are not both physically present. Examples include telephone calls, emails, writing letters to other health professionals, prescriptions, filling out forms for employment, etc. The Chronic Care Management fee is intended to cover the cost of providing more active care coordination for Medicare patients with two or more chronic health conditions. Diseases such as diabetes, hypertension, chronic obstructive pulmonary disease are examples that would meet the definition, and it is estimated that upwards of two thirds of Medicare patients would meet the two or more chronic disease criteria for this program’s payment.
The payment for CCM is expected to be $40 per patient per month. If there is no co-insurance coverage, the cost sharing for which the patients are responsible is $96/year, a sizeable amount if you are poor or on a fixed income. The new program requires that patients opt-in yearly with a written consent. How a lack of consent will affect the relationship between the patient and the doctor remains to be seen, especially now that many doctors are employed by hospital systems, and may not have the power to modify or waive payments. I think it’s obvious that there is a potential for health care disruption. To participate, a doctor must use a certified electronic health record and have 24/7 access. Not all primary care doctors have an electronic record, and this can be a considerable expense that may not be offset by the CCM payment. There is real concern that this added computer expense would be affordable only to large systems, and drive solo and small groups out of practice or into retirement. There is also no built in way to measure whether there is better quality or value in the program, so it is not beyond imagination that large and well organized systems could be paid for services that haven’t been proven to improve care.
While the promise of value- based and better coordinated health care is a laudable policy goal, there is concern that care could be disrupted, and there is no way to audit the outcomes in the program. I have my own concerns on whether decisions people make could put them at cross purposes to their doctor under this program. Patient choice on medications, vaccinations, etc. could be sacrificed on the altar of some bureaucrat’s definition of high quality health care. How this program evolves in the real world remains to be seen, but I think it is clear that the train is leaving the station. Stay tuned.
Dr. MacMillan specializes in Gastroenterology and Liver disease and is a member of the North Andover Board of Health. He practices at Holy Family Hospital and currently serves as President of the Massachusetts Gastroenterology Association. Dr. MacMillan was recently reelected as Massachusetts Governor of the American College of Gastroenterology and is a Fellow of the College.