An Ounce of Prevention is Worth a Pound of Cure
That’s right, preventing bad things from happening improves outcomes. This old saying has been applied to many topics - education, justice, environment and health to name a few. This saying has a special meaning for physicians treating Medicare patients today.
55 million on Medicare According to the Henry J. Kaiser Foundation, 55 million Americans are now have healthcare coverage under a Medicare plan. Primary Care Physicians (PCP) which includes physician with a Medicare specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine or an NPP with a specialty designation of Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), or Physician Assistant (PA) have new practice guidelines under Medicare starting with an incentive payment in 2011 for treating Medicare recipients. This incentive payment compensates PCPs for the office and home based services necessary for providing the most coordinated level of care. This change happened under the Affordable Care Act (ACA) along with a financial incentive to switch from a paper medical record to an electronic medical record. The Office of National Coordination (ONC) reports 54% of PCPs now use an EHR as of April 2015.
Patient Centered Medical Home The real Prevention incentive came just this past year with the new Chronic Complex Care Management (CCM) payment. The new Medicare reimbursement for CCM was adopted and codified on November 13, 2014, with an effective date of calendar year 2015. This groundbreaking change for the first time enables physicians to bill for enhanced non-face to face care management services using CPT code 99490. This is the new model of care coordination found most often in Patient Centered Medical Home model practices.
Complex Chronic Care Management Prevention focused care enables PCPs to address the highest risk/ highest cost individuals or those known to excessively utilize healthcare resources. Selected patients will include those with multiple health conditions (co-morbidities) that place them at higher risk for complications, decompensation, functional decline or even death. Examples of chronic conditions include, but are not limited to, the following: Alzheimer’s disease and related dementia; Arthritis; Asthma; Atrial fibrillation; Cancer; Chronic Obstructive Pulmonary Disease (COPD); Depression; Diabetes; Heart failure (CHF); Hypertension; Ischemic heart disease (IHD); and Osteoporosis.
Prevention saves money CMS changes emphasizing prevention is an effort to reduce the costly cure side of the equation. PCPs today practice under the tremendous pressure of seeing more patients with less resources with the expectation of high quality care. Something has to give. Patient Centered care is turning the tide away from hospital based cure to anticipating and treating conditions before they become life threatening events.