Management Code From CMS Found Wanting

Although Medicare's proposed complex care management billing code might seem like a help to patient-centered medical homes (PCMH), not all PCMH supporters like the idea.

Medicare -- the country's largest healthcare payer -- should move closer toward a per-member bonus for PCMHs and not perpetuate a fee-for-service model that has done little to stop skyrocketing healthcare costs, Chris Koller, president of the Milbank Memorial Fund in New York City, said here Monday.

"As long as Medicare -- the big gorilla -- is staying stuck in a fee-for-service world, we're not going to get the transformation we're looking for," said Koller, who served as the keynote speaker for the Fall Conference of the Patient-Centered Primary Care Collaborative (PCPCC), a PCMH stakeholder organization and advocate.

"We have to show CMS how to follow the example of private payers and move from straight fee-for-service to fee-for-service blended with primary care capitation to more capitation to some sort of shared risk," said Koller, who now runs a health reform endowment fund.

Medicare proposed earlier this year in its 2014 physician fee schedule a plan that willreimburse providers for the care management of patients with multiple, significant chronic conditions starting in 2015.

Medicare would pay for non-face-to-face services through separate G-codes for establishing a care plan and managing that care over 90-day periods. The Centers for Medicare and Medicaid Services (CMS) had hoped to finalize the 2014 fee schedule by the end of this month, but that time frame is likely delayed because of the ongoing government shutdown.

The fee, which would start in 2015, has been supported by primary care societies such as the American College of Physicians and the American Academy of Family Physicians.

Despite that support from organized medicine, Koller said providers and states with more experience in partial capitation payment forms such as a per-member-per-month bonus would like a more aggressive stance on payment reform.

"We gotta make that jump to per-capita payments," he told MedPage Today. "We've done enough experiments to know how to do per-capita payments."