WASHINGTON — Adjusting medications before someone gets sick enough to visit the doctor. Updating outside specialists so one doctor's prescription doesn't interfere with another's.
Starting this month, Medicare will pay primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don't have a face-to-face exam.
The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes.
"We all need care coordination. Medicare patients need it more than ever," said Sean Cavanaugh, deputy administrator at the Centers for Medicare and Medicaid Services.
About two-thirds of Medicare beneficiaries have two or more chronic conditions, such as diabetes, heart disease or kidney disease. Their care is infamously fragmented. They tend to visit numerous doctors for different illnesses.
Too often, no one oversees their overall health — making sure multiple treatments don't mix badly, that X-rays and other tests aren't repeated just because one doctor didn't know another already had ordered them, and that nothing falls between the cracks.
Medicare's new fee, which is about $40 a month per qualified patient, marks a big policy shift. Usually, the program pays for services in the doctor's office.
"We're hoping to spur change, getting physicians to be much more willing to spend time working on the needs of these patients without necessitating the patient to come into the office," Cavanaugh told The Associated Press.
To earn the new fee, doctors must come up with a care plan for qualified patients, and spend time each month on such activities as coordinating their care with other health providers and monitoring their medications. Also, patients must have a way to reach someone with the care team who can access their health records 24 hours a day, for proper evaluation of an after-hours complaint.
Many primary care physicians already do some of that.
"Quite honestly, I just didn't get paid for it," said Dr. Robert Wergin, president of the American Academy of Family Physicians.
Wergin estimates he spends about two hours a day doing such things as calling elderly patients who have a hard time visiting his office in rural Milford, Nebraska.
Say someone with heart failure reports a little weight gain, a possible sign of fluid buildup but not enough to make the patient call for an appointment. Wergin might adjust the medication dose over the phone, and urge an in-person exam in a few days if that doesn't solve the problem.
The new fee could enable physicians to hire extra nurses or care managers to do more of that preventive work, Wergin said. Patients must agree to care coordination; the fee is subject to Medicare's standard deductible and coinsurance. Wergin plans to explain it as, "This is how we're going to hopefully manage your illnesses better at home."
But for some patients, care coordination can require a lot more work.
It's like being a quarterback, Dr. Matthew Press wrote in the New England Journal of Medicine last summer in describing the 80 days between diagnosing a man's liver cancer and his surgery. The internist, while at Weill Cornell Medical College, sent 32 emails and had eight phone calls with the patient's 11 other physicians. That's something CMS' Cavanaugh said a doctor in private practice would find hard to squeeze in.
The chronic care management fee is one of multiple projects Medicare has underway in hopes of strengthening primary care, and in turn save money. For example, about 500 practices in a demonstration project involving Medicare and private insurers are receiving monthly payments, averaging $20 a patient, to improve care management and coordination for everyone, not just those at high risk.
Stay tuned: Medicare is tracking data on quality and costs to see if the experiment is working.