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For Very Sick Patients, Medicare Now Pays Doctors For More Than Medicine

A primary care provider who arranges a meal delivery service for a chronically ill patient can be paid for that time, under new Medicare rules.

In January, Medicare started paying primary care providers for non-face-to-face care coordination for parents with two or more chronic illnesses. Care coordination has been shown to extend the lives of such patients.

Sound Medicine host Barbara Lewis spoke with Dr. Louise Aronson, professor of Geriatrics at University of California San Francisco, about what the new rules mean for doctors and patients. Dr. Aronson says the new system, which reimburses doctors for arranging things like transportation and home food delivery, will help keep the very sick out of nursing homes.  

SM: How will the new rules change how care is delivered?


Louise Aronson: It's actually pretty terrific. A lot of primary care has to do with arranging services, dealing with medications and talking to patients and caregivers. And up until this point we've really only been reimbursed for face-to-face interactions. All kinds of other things that have known to be really good for care of patients were not reimbursed. It's been one of the strains on primary care that there's so much work that isn't counted in the fiscal sense. 

So this is really recognizing an essential part of primary care by adding a benefit that compensates physicians for it. 

SM: Why might people with two or more chronic illnesses need this service?

LA: It's not necessarily just for people with two chronic conditions, but [the rule includes] conditions expected to last more than a year, but with risk of death, decompensation or decreased function. For example, congestive heart failure. It wouldn't cover every chronic illness. 

SM: Dr. Aronson, give me an example of how this would work. I'm trying to imagine an example of someone in the primary care office coordinating care, and what that would mean.

LA: There are actually many different ways it can look. But you might know that somebody isn't doing so well. Imagine, if we stick with the heart failure example: Part of why they're eating what they're eating [could be] because they could only walk as far as the corner store. And at the corner store, because of their income or what they can carry, they eat foods that are loaded in salt. 

So they eat salt, and they decompensate, and they end up back in the hospital. So you might think "Oh, I'll get a meal delivery service." And then it turns out they've got other functional issues, and they're getting socially isolated and they're scared to go out and walk. So maybe if they went to a day center they would get more exercise. And that would lead to potentially the disease not only not getting worse, but it getting better, and then getting better on a variety of other metrics such as their arthritis, or depression, or a variety of other chronic diseases that often go with heart failure. 

So you would need to then coordinate with the meals service, you might need to get some care at home and deal with those caregivers and fill out paperwork, you might take some time working with a social worker to figure out which adult day center it would be. 

Then you might coordinate with the nurse at the day center to say "Hey can you follow these vital signs and this patient's weight?" because if it goes up this month I'm gonna be concerned that we're on the verge of an exacerbation. And if you call me I can then call you back - and get paid for that - and we can intervene before this person ends up in the hospital and suffers more decompensation and more functional loss. 

SM: How popular is it already, and how popular do you expect it to become? 

LA: It's pretty hard to say. It seems that some people are starting to try it. A lot of systems are looking into how to do this. It comes with a lot of requirements, like having electronic health records and staff with 24-hour access to it, and the coordination of transitions. There are just many ways you could implement it. I think because it's only been around for two months, people are trying out how to do it. 

To the degree that prices drive things, we're sort of transitioning from a fee-for-service sector as a health care society to a different one. On the other hand, the new one is more cost-conscious. So this is a way of incentivizing people to do what seems to be better care. I'm hoping it will become popular, and will also just be the first step towards more payment and system structures that support what we know leads to better care. Has it worked in every trial? No. But there's a lot of evidence to suggest it's better care for people. 

I think it really should lead to better care. It gives people all kinds of things which are very helpful:  Access to community and social services that can help them remain in their homes and functioning well. One of the things that older adults fear most is ending up in a nursing home. And as their burden of chronic disease increases, often they have functional and basic social challenges. So if their physician or the practice is incentivized to help them solve those problems so they can remain where they want to live and function as well as possible given their ailments, that's a huge plus.