Some Telehealth Visits, Care Coordination Win CMS Reimbursement, Published Reports Say

Starting in January, primary care physicians will be paid to coordinate care for Medicare patients and can be reimbursed for telehealth visits for wellness and behavioral health, according to a published report.

Modern Healthcare reported the change late Friday, but warned that physicians might see Medicare payments cut 21% if the sustainable growth rate (SGR) formula is not later revised. The report said CMS officials could not be reached for comment.

Primary care physicians have long sought reimbursement to fund case managers or navigators to coordinate care for patients seeing multiple providers. Following a proposal earlier this year, Medicare will cover wellness and behavioral health telehealth visits in early 2015. Also, physicians will be able to bill Medicare $40 per patient per month to coordinate care for patients with multiple chronic conditions.

Both steps are seen as essential elements of improving patient access to primary care and behaviorial health services, at a time when both fields are struggling to keep up with demand. The way that both fields have been reimbursed generally and by Medicare in particular has been seen as a challenge to getting PCPs and behavioral health practitioners to accept Medicare clients or to pursue care coordination strategies.

In the past year, annual meetings of the American Psychiatric Association and the American Diabetes Association featured presentations on the need to better coordinate primary and behavioral health to achieve better outcomes for each, but doctors peppered presenters with questions about how to fund the staff who would handle these tasks.

Telehealth is seen as a way to bring gaps in shortages of providers, to help those who have disabilities or would have to travel long distances, or to alleviate the need for busy professionals to leave work for appointments. At the October 16-17, 2014, meeting of the ACO and Emerging Healthcare Delivery Coalition, an initiative of The American Journal of Managed Care, attendees heard a presentation from Krista Drobac, executive director of the Alliance for Connected Care. Ms. Drobac said data show that patients who try telehealth overwhelmingly like it, but that in the past, regulatory limits on telehealth have curtailed its ability to boost access to care.

Meanwhile, the threat of SGR could undermine the progress of this change. Medicare’s SGR rule is a decade-old policy that was originally designed to slow growth in healthcare spending. Critics said its unrealistic estimates have caused annual stopgaps by Congress to avoid drastic cuts in payments to doctors. The most recent extension rolled out the deadline to April 1, when cuts of 21.1% are set to take effect.

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