Doctors have complained for years that they're not paid adequately for time-consuming work associated with managing care for seriously ill older patients: consulting with other specialists, talking to families and caregivers, interacting with pharmacists and more.
That will change on Jan. 1, as a new set of Medicare regulations go into effect.
Under the new rules, physicians will be compensated for legwork involved in working in teams -- including nurses, social workers and psychiatrists -- to improve care for seniors with illnesses such as diabetes, heart failure and hypertension.
Care coordination for these "high need" patients will be rewarded, as will efforts to ensure that seniors receive effective treatments for conditions such as anxiety or depression.
Comprehensive evaluations of older adults with suspected cognitive impairment will get a lift from new payments tied to the standards that physicians now will be required to follow.
The new Medicare policies reflect heightened attention to the costliest patients in the health care system -- mostly older adults who have multiple chronic conditions that put them at risk of disability, hospitalization, and an earlier-than-expected death. Altogether, 10 percent of patients account for 65 percent of the nation's health spending.
It remains to be seen how many physicians will embrace the services that the government will now reimburse. Organizations that advocated for the new payment policies hope they'll make primary care and geriatrics more attractive areas of practice in the years ahead.
Here's a look at what is entailed:
Complex Chronic Care Management
Two years ago, Medicare began paying nurses, social workers and medical assistants to coordinate care for seniors with two or more serious chronic conditions. But low reimbursement and burdensome requirements discouraged most medical practices from taking this on.
New payments for "complex chronic care management" are more generous (an average $93.67 for the first hour, $47.01 for each half hour thereafter) and can be billed more often, making them more attractive.
They'll cover services such as managing seniors' transitions from the hospital back home or to a rehabilitation center, coordinating home-based services, connecting patients with resources, and educating caregivers about their conditions.
Many practices will be able to hire care managers with this new financial support, said Dr. Peter Hollmann, secretary of the American Geriatrics Society and chief medical officer of University Medicine, a medical group practice associated with Brown University's medical school.
To illustrate the benefits, he tells of a recent patient, with diabetes, hypertension and heart failure who was retaining fluid and had poorly controlled blood sugar. After a care manager began calling the 72-year-old man every few days, asking if he was checking his blood sugar or gaining weight, Hoffmann adjusted doses of insulin and diuretics.
"The patient remained at home and he's doing well, and we likely prevented a hospitalization," Hoffmann said.
Cognitive Impairment Assessment
Making a dementia diagnosis is difficult, and primary care physicians often fail to do so on a timely basis. But new Medicare policies may help change that by specifying what cognitive examinations should entail and offering enhanced payments.
Physicians who conduct these evaluations are now expected to meet 10 requirements. In addition to performing a careful physical exam and taking a detailed history, they need to assess an older adult's ability to perform activities of daily living, their safety, behavioral and neuropsychiatric symptoms, and caregivers' knowledge, needs and abilities.
All the medications the senior is taking should be evaluated, and standardized tests used to assess cognition. Efforts to elicit the patient's goals and values need to occur in the context of advance planning, and a care plan must be crafted and shared with caregivers.
Medicare will pay $238.30 for the initial assessment and additional fees for creating a care plan and performing care management.
"Hopefully, this will kick start the development of practices that provide these dementia-related services," said Dr. Robert Zorowitz, senior medical director at OptumCare CarePlus, a managed Medicare long-term care program in New York City.
Care Between Patient Visits
Until now, the rule has been: if the doctor is with a patient, he can bill for his time. But if he takes home medical records to review at night or talks by phone with a caregiver who's concerned about her elderly mother, that time goes unpaid.
That will change next year: Medicare will begin paying $113.41 for the first hour spent in these kind of activities and $54.55 for every subsequent half hour.
For the first time, "this recognizes the significant and valuable services that physicians perform in between face-to-face visits," said Dr. Phillip Rodgers, co-chair of the public policy committee at the American Academy of Hospice and Palliative Medicine.
Physicians will also get extra reimbursement for extra time they spend in person with complex patients or their caregivers.
Dr. Paul Tatum, an associate professor of clinical family and community medicine at the University of Missouri School of Medicine recently scheduled a half hour for a patient in his mid-70s with high blood pressure, kidney disease, skin issues and cognitive impairment. But the visit ran to 90 minutes when it became clear the gentleman was more confused than ever, falling, not eating well, not taking medications, and needed more help.
"Much of what we did for this patient fits in the new Medicare codes, which recognize the extent of what's needed to care for people with complex illnesses," the doctor said.
Integrating Behavior Health
Research has shown the seniors with depression -- a frequent complication of serious illness -- benefit when primary care physicians collaborate with psychologists or psychiatrists and care managers track their progress.
Now, Medicare will begin paying $142.84 for the first 70 minutes that physicians and behavioral health providers work together, $126.33 for the next hour, and $66.04 per half hour for a care manager who stays in touch with patients and tracks whether they're improving.
Care managers may work on site or off; psychologists and psychiatrists will be called for consultations, as needed.
"Accessing mental health services is a really big problem for my patients, and having professionals ready to work with me and compensated to do so will be extraordinarily valuable," said Rodgers of the hospice and palliative medicine academy.
KHN's coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.