Chronic Care Management: A Game Changer
If you're at all familiar with the history of football, you know that the sport has evolved greatly over the past 200 years. American football arose in the early 19th Century from a disorganized game played by violent mobs. It was a sport in which injury—and death—were not uncommon. Even after standardized rules were introduced in the 1870s, the game remained extremely dangerous due to brutal tactics like the flying wedge formation.
The brutality of football reached its peak in 1905, when a multitude of deaths and horrible injuries shocked the public into action. There were calls from many quarters to outlaw the game. Harvard—birthplace of the flying wedge—considered banning the sport, and Stanford, California, Duke, Columbia, and Northwestern actually shut down their teams. At this point, President Theodore Roosevelt stepped in and convened a meeting of college coaches to determine how to make the game safer. Out of this meeting arose a number of changes, giving birth to a governing body that would eventually become the NCAA. The rules were reformed, the flying wedge was banned, and the forward pass was introduced. It was literally a game changer.
A game changer is a person, idea, or event that forever changes the current way of doing or thinking about something. That’s what the 1905 reforms did for football. Modern fans would hardly recognized the old game. What Roosevelt set in motion not only completely changed the game—it saved it. Without those reforms, football might not have survived.
Primary care medicine also needs a game changer. Like pre-1905 football, primary care is in crisis, and the rules that govern the "game" are broken. The Relative Value System and Sustainable Growth Rate formula create a playing field that consistently undervalues the service of primary care physicians. Meanwhile, new competitors, like retail and worksite clinics, are skimming off the low-intensity services that used to help maintain our office cash flow. Consequently, primary care physicians are left with an ever rising volume of complex patients who require more time and have more restrictive insurance coverage.
To make matters worse, the performance expectations for primary care physicians have never been higher. We are expected to provide high-quality preventive care, even though it would take an additional 7.4 hours per day to provide all of the US Preventive Services Task Force recommendations. Added to this are the burdens of Meaningful Use and downward pressure on staffing levels. There are simply not enough hours in the day or staff resources to do everything that is expected of us using the traditional model of care. Without practice transformation and payment reform, there is a real possibility that many primary care practices will not survive, leaving patients with an increasingly fractured healthcare system.
All of these challenges arise at a time when population demographics make it even more important to have a robust primary care system. In 2011, the first wave of Baby Boomers became eligible for Medicare, and over the next 15 years the number of people over the age of 65 will double. As the elderly population grows, the proportion of patients with chronic and complex diseases will explode.
Medicare has long recognized that chronic care management is “where the money is.” More than two-thirds of Medicare beneficiaries have two or more chronic conditions such as hypertension, diabetes, and COPD. Considering the entire population, chronic conditions account for 85% of all healthcare spending. Multiple studies have confirmed that chronic care management can reduce healthcare costs while improving outcomes. Unfortunately, physicians have had little incentive to provide chronic care management services due to a lack of reimbursement for non-face-to-face services.
Starting this year, Medicare will pay for chronic care management services (CPT 99490), including time spent by our clinical staff. These non-face-to-face activities include performing medication reconciliation, providing education, answering questions from family members and caregivers, arranging community resources, and managing care transitions. Finally there will be a payment model that can make the patient-centered medical home financially viable. This is truly a game changer with the the potential to transform primary care as much as the forward pass transformed the game of football.
Of course, there are still many unanswered questions about the new service and how the new fee will affect the bottom line of our practices. The AAFP has published a helpful review of chronic care management and has provided tools for implementation on its website. Once again the Academy has demonstrated its value as an advocate for system-wide reform. We should continue to support the Academy as a steadfast champion of practice transformation, and a key player in lobbying for this new service.
One day we may look back on 2015 as a game-changing year. Perhaps this new CPT code will be the impetus for industry-wide payment reform that will finally shift us away from the encounter-based fee-for-service system toward a value-based system. Maybe we’ll mark this year as the beginning of meaningful practice transformation. Hopefully, patient’s will remember this year as the beginning of a new age of patient-centered care. It’s also possible that the events of 2015 will be only one of many tiny steps toward achieving the health care system that our patients deserve. Time will tell, but like football circa 1905, the best way to save our “game” is to change it.
This article was published in South Carolina Family Physician.
The brutality of football reached its peak in 1905, when a multitude of deaths and horrible injuries shocked the public into action. There were calls from many quarters to outlaw the game. Harvard—birthplace of the flying wedge—considered banning the sport, and Stanford, California, Duke, Columbia, and Northwestern actually shut down their teams. At this point, President Theodore Roosevelt stepped in and convened a meeting of college coaches to determine how to make the game safer. Out of this meeting arose a number of changes, giving birth to a governing body that would eventually become the NCAA. The rules were reformed, the flying wedge was banned, and the forward pass was introduced. It was literally a game changer.
A game changer is a person, idea, or event that forever changes the current way of doing or thinking about something. That’s what the 1905 reforms did for football. Modern fans would hardly recognized the old game. What Roosevelt set in motion not only completely changed the game—it saved it. Without those reforms, football might not have survived.
Primary care medicine also needs a game changer. Like pre-1905 football, primary care is in crisis, and the rules that govern the "game" are broken. The Relative Value System and Sustainable Growth Rate formula create a playing field that consistently undervalues the service of primary care physicians. Meanwhile, new competitors, like retail and worksite clinics, are skimming off the low-intensity services that used to help maintain our office cash flow. Consequently, primary care physicians are left with an ever rising volume of complex patients who require more time and have more restrictive insurance coverage.
To make matters worse, the performance expectations for primary care physicians have never been higher. We are expected to provide high-quality preventive care, even though it would take an additional 7.4 hours per day to provide all of the US Preventive Services Task Force recommendations. Added to this are the burdens of Meaningful Use and downward pressure on staffing levels. There are simply not enough hours in the day or staff resources to do everything that is expected of us using the traditional model of care. Without practice transformation and payment reform, there is a real possibility that many primary care practices will not survive, leaving patients with an increasingly fractured healthcare system.
All of these challenges arise at a time when population demographics make it even more important to have a robust primary care system. In 2011, the first wave of Baby Boomers became eligible for Medicare, and over the next 15 years the number of people over the age of 65 will double. As the elderly population grows, the proportion of patients with chronic and complex diseases will explode.
Medicare has long recognized that chronic care management is “where the money is.” More than two-thirds of Medicare beneficiaries have two or more chronic conditions such as hypertension, diabetes, and COPD. Considering the entire population, chronic conditions account for 85% of all healthcare spending. Multiple studies have confirmed that chronic care management can reduce healthcare costs while improving outcomes. Unfortunately, physicians have had little incentive to provide chronic care management services due to a lack of reimbursement for non-face-to-face services.
Starting this year, Medicare will pay for chronic care management services (CPT 99490), including time spent by our clinical staff. These non-face-to-face activities include performing medication reconciliation, providing education, answering questions from family members and caregivers, arranging community resources, and managing care transitions. Finally there will be a payment model that can make the patient-centered medical home financially viable. This is truly a game changer with the the potential to transform primary care as much as the forward pass transformed the game of football.
Of course, there are still many unanswered questions about the new service and how the new fee will affect the bottom line of our practices. The AAFP has published a helpful review of chronic care management and has provided tools for implementation on its website. Once again the Academy has demonstrated its value as an advocate for system-wide reform. We should continue to support the Academy as a steadfast champion of practice transformation, and a key player in lobbying for this new service.
One day we may look back on 2015 as a game-changing year. Perhaps this new CPT code will be the impetus for industry-wide payment reform that will finally shift us away from the encounter-based fee-for-service system toward a value-based system. Maybe we’ll mark this year as the beginning of meaningful practice transformation. Hopefully, patient’s will remember this year as the beginning of a new age of patient-centered care. It’s also possible that the events of 2015 will be only one of many tiny steps toward achieving the health care system that our patients deserve. Time will tell, but like football circa 1905, the best way to save our “game” is to change it.
This article was published in South Carolina Family Physician.