Medicare's Transitional Care Payment — A Step toward the Medical Home (New Eng Jour Med)

[pinto]

I was recently treated under a similar format. Was in-patient for a surgical procedure, five days. My care there was coordinated by a hospitalist - an MD who's primary role was to see that all medical teams were in sync with my care, from surgical follow up to nursing and even nutritional services.

On discharge, Medicare covered daily post-op care nursing visits at home for a week. This was under the surgeon's purview, but he didn't need to see me, either at home or in office. Nursing staff gave him daily reports electronically. By phone when necessary. He agreed with the in-home RN team assessment that another week of tapering visits was appropriate for wound care and follow-up. All went smoothly. ~ pinto

Medicare's Transitional Care Payment — A Step toward the Medical Home

Andrew B. Bindman, M.D., Jonathan D. Blum, M.P.P., and Richard Kronick, Ph.D.
N Engl J Med 2013; February 21, 2013

Many health care experts believe that primary care is the foundation on which to build a high-performing health care system, with maximized quality and reduced costs.1 The Affordable Care Act (ACA), in an acknowledgment of primary care's importance, includes a 10% payment bonus for primary care physicians participating in Medicare between 2011 and 2015. This fee-for-service payment incentive does not require primary care physicians to change the way they provide or document their services.

Although 27% of Medicare beneficiaries are now in managed care (Medicare Advantage) arrangements2 and the Centers for Medicare and Medicaid Services (CMS) is testing other new payment models, fee for service is likely to remain the dominant Medicare payment model for years to come. Not only will it take time to test and implement new models, but even after they're implemented, fee-for-service payment levels will probably be used as benchmarks for allocating risk-sharing payments in accountable care organizations.

With the publication of its 2013 physician-payment rule, however, CMS took an important step in promoting a new method of enhancing payments for primary care services that will encourage a change in the structure and process of delivery.3 The first step of this transition is CMS's adoption of new Current Procedural Terminology (CPT) codes under which it will provide bundled payments to physicians for managing patients' transition back to the community after discharge from a hospital, rehabilitation facility, or skilled nursing facility. The transitional care payment will provide physicians with enhanced compensation, which will vary with the complexity of the patients' needs, for specified non–face-to-face care-coordination services plus an office visit within 7 to 14 days after a discharge. In time, CMS expects to eliminate the requirement for the physician visit as a part of its plan to promote payment for care-coordination services delivered in advanced primary care practices.

CMS's overall strategy involves improving quality and reducing costs by investing in care coordination that could help reduce hospital-readmission rates. The ACA authorizes payment penalties for hospitals that have high readmission rates for Medicare beneficiaries. Physicians are not subject to these penalties, but the roles they and their staffs play in discharge planning and care coordination after discharge strongly affect the likelihood of readmission. CMS has had a discharge-day management code in place for hospital-based physicians since 1996. The new transitional care code permits a corresponding payment to community-based physicians who accept responsibility for coordinating discharge plans and ensuring that they're reconciled with other ongoing care. For physicians of patients who need highly complex medical decision making after discharge, the new payment will provide approximately $55 beyond the $143 for the office visit for transitional care services during the 30 days after discharge.

http://www.nejm.org/doi/full/10.1056/NEJMp1214122?query=health-policy-and-reform

[KT2000]

1. sounds like an improvement

My brother spent 10 days in the hospital for major surgery. He went home to the care of his wife who did a good job but has no medical training. The stress on her was incredible. He was on heavy pain meds and antibiotics for infection - he was not always cooperative either. He just wanted to be left alone.
She ended up buying just about every medical device she could to monitor his condition.
It is amazing how people are released with instructions and a followup appointment weeks away and that's it.

My brother had issues with persistent infection that could have really gone bad had my SIL not been as bright and insistent as she was. I can see how it could easily turn out badly.

[pinto]

2. Sorry to hear that, glad it worked out. In my case I was discharged and the in-home referral

was already in place. I assume the hospitalist and the surgeon conferred on discharge. Not sure, I was pretty dopey. In any event, I saw an RN at home the next day. To put it in context, though, I had a drain tube in the incision so it had to be monitored / emptied daily. I remember suggesting I'd take care of it, but both MD's just grinned slightly and shook their heads. Nope.

Hope your brother is well.

[KT2000]

5. thanks

he is returning to work in a few days!

[frazzled]

3. This past month I arranged for Medicare-paid home nursing visits for my father

after a seven-day hospitalization for flu and pneumonia (he's 96). I was with him daily in the hospital (all day: you can't expect nursing staff to attend to much more than medical orders), and stayed in town a few days after his release to make sure things were set up well at my parents' house before I had to return home.

But it was a real reassurance to have a fully-paid, professional nurse come in to check on his vitals (especially his blood sugar levels, which had gone whack from the illness and from being taken off his regular medication) and his mobility, to make sure there were no issues for safety and no relapse. I was there for the first visit, and the nurse was superb.

I must say, I had to request this from the hospital when discharge was being set up, but they were extremely efficient in arranging it. Since it wasn't surgery, I don't believe there was follow-up with the hospital doctors. But they did make an appointment for him with his primary physician for about five days after the release. For this, I arranged for a "senior companion" to come to the home and drive him and my mom to the appointment. We wanted the helper to come for four hours a day for the first week, but my parents said they had nothing for them to do after two visits, and "fired" the helper!

There was no relapse into illness, and my dad is now back to driving short distances and going to the gym. He's disappointed in himself because he can't do the twenty-five miles on the stationary bike he was doing before the pneumonia--only five. Heck, I can't even do five! I told him it will take at least three months to recuperate, but he's not buying it.

Yay, Medicare.

[pinto]

4. Kudos. You, your family, community support and the professional team worked.

[jsr]

6. Recommend