Sunday, November 30, 2014

Primary Care Pay Protocols

Our life is frittered away by detail..Simplify, simplify.

Thoreau (1817-1862), Walden

I see in the New England Journal of Medicine that Medicare proposes to pay primary care doctors by protocol (S.T. Edwards and B.E. Landon, “Medicare Chronic Care Management Payment – Payment Reform for Primary Care,” November 27, 2014). The idea is you pay doctors $40 a month for patients who have 2 or more chronic illnesses if they scrupulously follow federal protocols.

This is necessary, say CMS officials , because fee-for-service is not up to the job of offering continuous across the diagnostic, clinical, and treatment spectrum.

Or to put it in more elegantly as the NEJM authors do , “The fee-for-service system…is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medical refills, and care provided electronically or by telephone. “

“Chronic care management (CCM) is a critical step forward in recognizing the essential features of primary care – continuity, whole person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination.”

Therefore, primary care practices caring for Medicare patients with 2 or more chronic diseases expected to last last at least 12 more months that have a risk of death, decompensation or functional decline (more than 2/3s of beneficiaries) can receive a monthly fee of about $40 per patient) provided they stick to the CMS protocol.

This payment assumes the primary care physician will follow a rigid protocol ( scope of services required to bill Medicare for Chronic Care Management (CCM) services). Requirement include having an electronic health record (EHR), 24/7 communication access, a documented patient-centered plan, and a problem list, including documents outlining, expected outcome and prognosis, measurable treatment goals, symptom management plan, planned interventions, medication management plan, list of community and social services ordered, plan for directing and coordinating outside services, identifications of persons responsible for each intervention, requirements for periodic review and revision of care plan.”

In short, more paperwork, more of the government document obsession , with the thought that more documentation will improve quality and will result in a “value-oriented health system.”

In the NEJM authors' opinion, the government’s protocol is unlikely to work for a host of reasons.
I concur.

The federal Care Management protocol, with all of its folderol and additional investments required, will drive primary care doctors out of traditional practice into concierge practices, into the arms of hospitals, or into retirement.

The Devil, behind the coming failure of chronic care management (CMM) protocol, will be in the Details.

CMS would explain:

“Modern clinical protocols are needed to identify, summarize and evaluate the highest quality evidence and most current data about prevention, diagnosis, prognosis, therapy including dosage of medications, risk/benefit and cost-effectiveness. Then they must define the most important questions related to clinical practice and must identify all possible decision options and their outcomes. Some guidelines must contain decision or computation algorithms to be followed. Thus, they must integrate the identified decision points and respective courses of action with the clinical judgment and experience of practitioners. Many guidelines place are needed as the treatment alternatives to be placed into classes to help providers in deciding which treatment to use.”

To which I say, in the words of W.S. Gilbert in The Mikado, This is “merely corroborative detail, intended to give verisimilitude to an otherwise bald and unconvincing narrative.”

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