Key Services for the Medical Home

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Key Services for the Medical Home

• A.D. Jacobson, MD, FAAP

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Why a Patient-Central Medical Home?

• Method to improve U.S. health care system
  transforming change in health care financing and
  delivery
• Primary care practices will be more accessible,
  promote prevention, proactively support patients
  with chronic diseases
• Engage patients in self-management and
  decision-making
• End result will be better care, lower costs to
  payers and increased patient satisfaction

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Proposed Local Research in the Medical Home Model

• Phoenix Childrens Hospital is presently applying
  for a grant to study medical home concept and
  payer savings
• Will use 10 pediatric practices/clinics to study
  over a one-year period
• Practices will be open evening hours, weekends,
  and holidays, and use telephone triage services
• Will compare total per member/per month costs,
  hospital and ER utilization PM/PM, and the
  average cost of all members per month of the
  leading carriers in Arizona
• Expect these practices to have lower costs for
  the carriers compared to all practices

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Key Services for the Medical Home

• Evaluation and Management of Services
  Non-Face-to-Face Services

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Why a Key Service for the Medical Home?

• About one third of care in a pediatric medical
  home is delivered by telephone
• Maintaining an excellent telephone system is
  resource intensive both yours and your nurses
  time thus a need for payment

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Reimbursement Keys

• These are new codes payment will be dependent
  on billing volume, educating payers and employers
  at multiple levels, and contracting

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AAP Policy Statement

• Payment for Telephone Care
• AAP supports payment for telephone care services
  provided by pediatric providers triage and
  advice, care coordination, patient education, and
  chronic disease management.
• Pediatrics 2006 118 1768-1773

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Pediatric Telephone Care

• 2,000 3,000 calls/year/MD
• 10 15 clinical calls/day/MD
• 27 of decisions to see a specialist made over
  the phone
• Significant chronic care disease management done
  over the phone

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Telephone Care is Good Medicine

• Triage and Advice
• Disease and Case Management
• Medication Adjustments
• Acute Illness care
• Test Result Interpretation
• Counseling
• Patient Education

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Reasons for Increasing Use of the Telephone

• Ease everyone is attached to a cell phone
• Convenience no waiting in the office
• Safe
• Dual-working families
• Doctors pushed to see more patients

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Telephone Care is Safe

• Goal of study to assess
• Frequency of death or potential under-referral
  associated with hospitalization within 24 hours
  after a call
• Factors associated with potential under-referral
• Results
• No deaths occurred within lt 1 week after-hours
  calls
• Rate of potential under-referral with subsequent
  hospitalization was 0.2, or 1 case per 599
  triaged calls
• Source Pediatrics. 118(2) 457-63, 2006

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Patients Listen to Telephone Care

• Goal of study to assess
• Compliance with telephone triage nurse advice
• Results
• Rates of compliance with both urgent and home
  care disposition recommendations were 74
• Rate of compliance with next day recommendations
  was 44
• Source Pediatrics. 118(2) 457-63, 2006

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Cost of MD Taking Clinical Calls

• Direct costs
• 7,000 per pediatrician/yr.
• If other staff takes calls, increased expense.
• Opportunity Costs
• MD takes 3-5 min. (avg. 4) to answer each call
• Non-reimbursement time
• MD bills approximately 360/hr. (conservative) or
  6.00/min.
• Opportunity cost of MD doing triage is
  240-360per day or at least 60,000/yr.

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Reasons to Change

• The provision of after-hours telephone care
  results in an average savings for payers of 56
  per call
• Pediatrics 2007 119 e305-e306
• The provision of physician telephone care to
  those patients a nurse refers to an ED (SLT)
  decreases the number of ED visits by 50 leading
  to savings for payers
• Reducing After-Hours Referrals by an After-Hours
  Call Center with Second-Level Physician Triage
  Pediatrics, July 2000 106 226-230

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Physician Telephone Services 2008

• 99441 Telephone evaluation and management
  service provided by a physician to an established
  patient, parent, or guardian not originating from
  a related E/M service provided within the
  previous 7 days nor leading to an E/M service or
  procedure within the next 24 hours or soonest
  available appointment 5 -10 minutes of medical
  discussion
• 99442 11-20 minutes of medical discussion
• 99443 21-30 minutes of medical discussion

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Telephone Services Provided by Non-Physicians

• 98966 5-10 minutes of medical discussion
• 98967 11-20 minutes
• 98968 21-30 minutes

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Telephone Services Provided by Non-Physicians

• Clinical staff (RN) can report these codes
• Service provided must fall within the state scope
  of practice laws
• Established practice protocols are followed
• The physician group assumes responsibility for
  the practice expenses quality and professional
  liability of the telephone service provided or
  via a legal contract with a telephone advice
  entity
• The patient is established (i.e., not a new
  patient)
• All patient charges originate only from the
  physicians office or clinic and not from an
  outsourced call center or other entity

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Online Services New for 2008 Category I

• 99444 or E-mail visit
• Online E/M service provided by a physician to an
  established patient, guardian, or health care
  provider not originating from a related E/M
  service provided within the previous 7 days,
  using the Internet or similar electronic
  communication network

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Reasons for Supporting National Trend for
Telephone Care

• Equivalent healthcare outcomes at lower costs
• Affordable to payers and patients
• Widespread adoption of medical home model and
  reliance upon PCP
• Relieving pressures on overcrowded, understaffed
  hospital EDs for non-urgent care
• Expanded practice options and paid accessibility
  for physicians
• Patient-centered care (giving consumers
  flexibility and options when the choice is safe,
  reasonable, and appropriate)
• Source A Model for Telephone Medical Consults
  Guidelines for Decision-Makers, April 2008,
  Tommy G. Thompson et al

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Making the Business Case to Payers

• Top 10 Reasons to Provide Telephone Care
• Telephone Care has been proven to
• Reduce costs for chronic care
• Reduce referrals to UCC and ED
• Reduce unnecessary office visits
• Increase compliance and patient satisfaction
• Be effective in patient education and training
• Improve adherence to treatment protocols
• Be an integral part of case management and the
  medical home, prevent fragmentation of care
• Improve accessibility to PCP services
• Give consumers more options
• Increase patient satisfaction with PCP, health
  plans

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Key Services for the Medical Home

• Evaluation and Management of Services Care
  Plan Oversight

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Why a Key Service for the Medical Home?

• Allows reimbursement for managing chronic illness
  and behavior
• Pays for all non face-to-face time not billed
  with other non face-to-face codes
• Reimbursement Keys
• These codes are paid at the 30 minute level by
  most payers
• Will need a system for tracking/reporting time

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Care Plan Oversight Implementation

• Develop a tracking system
• Document all CPO activities in chart based on
  time
• Maintain a list of patients with CPO activity
• Pull charts and tally all minutes at the end of
  the calendar month
• Educate families about billing

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Care Plan Oversight

• Care Plan Oversight Services are reported
  separately from codes for office/outpatient,
  hospital, home, nursing facilities or domiciliary
  services
• The complexity and approximate physician time of
  the care plan oversight services provided within
  a 30-day period determine code selection
• Can only be reported by one physician
  (PCP/Medical Home Provider) to reflect that
  physicians sole or predominant supervisory role

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Care Plan Oversight Activities

• Review of subsequent reports of patient status
• Review of related laboratory and other studies
• Communication (including telephone calls) for
  purposes of assessment or care decisions with
  heath care professional(s), family member(s),
  surrogate decision maker(s) (e.g., legal
  guardian) and/or key caregiver(s) involved in
  patients care
• Integration of new information into the medical
  treatment plan and/or adjustment of medical
  therapy, within a calendar month

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Care Plan Oversight Home Health

• Physician supervision of a patient under care of
  home health agency, in home, domiciliary or
  equivalent environment requiring complex and
  multidisciplinary care modalities involving
  regular physician development and/or revision of
  care plans, etc., within a calendar month
• 99374 15-29 minutes
• 99375 30 minutes or more

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Care Plan Oversight for the Rest of Us
2006 New codes added for domiciliary, Rest Home
(e.g. Assisted Living Facility), or Home Care
Plan Oversight Services

• 99339 Individual Physician supervision of a
  patient (patient not present) in Home,
  domiciliary or rest home (e.g. assisted living
  facility) 15-29 minutes calendar month
• 99340 30 minutes or more

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Key Services for the Medical Home

• Special Services

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Why a Key Service for the Medical Home?

• Allows reimbursement for keeping your office open
  expanded or after hours
• Parents and payers should find value in avoiding
  the ER waits/ cost and being seen after hours or
  urgently by their own physician
• Reimbursement Keys
• Some of these codes are new and underutilized
• Will need a system for tracking/reporting time
• Medicare pays for none
• Payment is proportionate to their use and
  contracting
• Always add on to the base E/M service

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Special Services

• 99050 Service provided other than regularly
  scheduled office hours or on days when office is
  normally closed
• 99051 Service provided during regularly scheduled
  evening, weekend and holiday hours, in addition
  to basic services
• 99058 Service provided on emergency basis which
  disrupts other scheduled office services, in
  addition to basic service

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When 99051 is Being Used

• After hours (e.g., after 530 pm)
• Saturdays
• Sundays
• Holidays (including legal holidays such as Martin
  Luther King, Jr. Day, Veterans Day, Independence
  Day, and Labor Day)
• Communicate With Parents
• Inform the patients/parents when they are
  scheduling the appointment about the charge,
  especially if the office is open and seeing
  patients (e.g., patient will be seen on Labor
  Day, when the office is normally open, but will
  be charged a surcharge)
• Post a sign in the waiting room
• In cases in which insurance companies place
  financial responsibility on the subscriber, be
  sure to let the parents know about the surcharge
  you may also want to have them sign an advance
  beneficiary notice
• Be sure to have your current office hours on file
  with your carrier as well as posted in your
  office and on your business cards you may also
  want to have them on your office voice mail
  message

I understand that ______________ insurance does
not provide benefits coverage for the fee for
physician visits that take place during evening
hours or on a weekend or holiday. If my child is
see by physician of _____________ on a weekend or
holiday, I will be responsible for the payment of
the service. Signature Guarantor/Guardian
_________________________ Date
_________________ Signature Witness
___________________________________
Date _________________