PCMH: Systematizing Patient-Centered Medical Home Transformation

Systematizing Patient-Centered Medical Home Transformation

With the rise of patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), it is important for managed care professionals to understand how these models can improve care value. The key? Implementing care coordination practices, and incorporating new payment codes for transitional and chronic care management, said Lani Alison, BSN, director, care coordination & outcomes, Center for Clinical Excellence & Innovation, Bon Secours Health

System, Inc. First Report Managed Care also asked members of its Editorial Advisory Board to weigh in on the value of these emerging alternative pay models.

During the PCMH Congress 2015, Ms Alison emphasized that systematic implementation of care coordination is a hallmark of a high-performing organization that requires a team-based approach to support collaboration and communication among physicians, patients, and others. It includes a single plan of care across settings and providers, as well as shared decision-making.

The twin goals of core coordination, she said, are to:

1. Transfer information such as medical history, medication lists, test results, and patient preferences.

2. Establish accountability as to who is responsible for each aspect of care.

Components of care coordination include linking patients with community resources, providing care management services to high-risk patients, integrating behavioral health and specialty care into care delivery, tracking and supporting patients in obtaining and using services outside the practice, following up with patients within a few days of hospital discharge or emergency department visit, and communicating test results and care plans to patients and their families.

These factors lead to delivery of value-based care, and minimize hospital admissions and readmissions— key goals for managed care professionals. “Ensuring that all physicians involved with a patient’s care are aware of any pertinent changes in a patient’s plan of care, especially during transitions of care is key,” noted Barney Spivack, MD, national medical director, Medicare Case & Disease Management, OptumHealth.

“Care coordination can absolutely lead to delivery of value-based care,” added Jeffrey Dunn, PharmD, Senior VP, VRx Pharmacy Services. “The keys to improved outcomes and lower costs are risk alignment and multistakeholder (provider, patient, payer, and pharma) collaboration. “Managed care is in the unique position of supporting or managing this process as it currently

holds the risk, has more complete information, and has the resources to immediately impact care,” he continued. “Education on the model, implementation, and execution is crucial. Payers also need to measure and report outcomes in order to grow the concept and their role.”

Ms Alison highlighted 5 care coordination transitions based on standards provided by the National Committee for Quality Assurance (NCQA) (Table 1). Through systematic care coordination practices, she said, PCMHs and ACOs stimulate integration across the care continuum to achieve the desired outcomes of decreasing overall cost of care, improving patient experience, and improving quality of

care. These outcomes are based on measuring length of stay, readmissions, and patient experience.

Challenges of systematizing care coordination include variations in state regulations, private payers, and within PCMHs, as well as difficulties implementing new payment codes. Ms Alison emphasized several innovations in care coordination, such as including community care managers during bedside patient rounds and using self-management tactics through technology.

Ms Alison also discussed new payment codes that support systematized care coordination. These TCM codes are for services for patients during transitions from an inpatient setting or skilled nursing facility to a community setting, and include 2 CPT codes (99495 for moderate complexity and 99496 for high complexity). Both codes, she said, require communication with the patient within 2 days of discharge, and billing needs to be done 30 days after acute care

discharge.

For chronic care management (CCM), she said that as of January 2015, Medicare pays for some nonface- to-face care management services, including development and maintenance of a plan of care, communication with other health professionals, and medication management. Claims for CCM services (CPT code 99490) can be submitted when at least 20 minutes of services are provided subject to deductibles and coinsurance.

Patients eligible for CCM include those with multiple, significant chronic conditions; those at significant risk of death, acute exacerbation/decompensation, or functional decline; and those with an established, implemented, revised, or monitored comprehensive care plan.

Dr Spivack noted that although two-thirds of Medicare beneficiaries have ≥2 chronic conditions and may be eligible to receive these billable services, few CCM bills have been submitted for reimbursement.

One challenge to billing, said Ms Allison, is that several codes cannot be billed during the same

months as CCM (Table 2). The financial implications of CCM payment for primary care practices was estimated to be between $230 and $485 of net revenue increase per enrolled patient per year in a recent study by Basu et al (Ann Intern Med. 2015;163[8]:580-588). “The advantage of team care and the use of nonphysicians to provide at least some chronic disease management services has been emphasized,” said Dr Spivack.

Ms Alison ended her presentation by talking about the components of a care plan. At minimum, according to CMS, a care plan must include the problem, the goal (target outcome), and patient instructions.

Other components of a care plan that aims to deliver value-based care include patient preferences, treatment goals, assessment of potential barriers to meeting these goals and strategies for addressing barriers, care team members, current problems and medications, medication allergies, and a self-care plan.—Mary Beth Nierengartena