A code for improving transitions of care

New Medicare code for transitional care management has seen low uptake but good patient outcomes.

Back in 2013, as part of efforts to improve outcomes and reduce readmissions of recently hospitalized patients, Medicare began offering an extra payment for physicians managing the transition from hospital to outpatient care.

Payment codes for transitional care management require that the practice receiving the patient contact him or her within two days of discharge and have an in-person visit within seven days of discharge for patients with highly complex conditions and within 14 days for moderately complex conditions. Physicians then bill for transitional care management after 30 days from the discharge date.

Photo courtesy of Dr Bindman
Photo courtesy of Dr. Bindman

To see the impact of the new policy, researchers analyzed claims from more than 18 million fee-for-service beneficiaries discharged from a hospital or other facility from 2013 to 2015. The results were published online in July and in the September issue of JAMA Internal Medicine, and co-author Andy Bindman, MD, FACP, a professor of medicine at the University of California, San Francisco, recently discussed them with ACP Hospitalist.

Q: What motivated this study?

A: Personally, I had been involved in developing the code. This study was really meant to see is the payment being utilized? And is it having the intended impact on improving patients' health? And is it contributing in any way to reducing overall health care costs?

Q: What did you think of the study's answers to those questions?

A: We thought they were quite striking. It's being underutilized; at least it was in those initial years. To some extent, you could anticipate that it takes a while for physicians to learn about opportunities for new payment. But even three years after being able to get paid for the service, we were only seeing that in about 7% of potential discharges was there a physician billing Medicare for it. It was growing slowly over time, but it was slower than we might have anticipated. Having said that, we saw that when they transitioned from the hospital back to the community and the service was being provided, it was about a 10% reduction in total health care costs. Mortality rates were also significantly decreased, so what had been a death rate of about 1.6% among all discharges dropped to 1% for those that received transitional care management services. That suggests to us that this can be a very effective intervention, but that it's not being fully utilized.

Q: Why do you think the code wasn't used more?

A: We don't have a way to directly measure why is it that physicians are not using the service, but we do get a few clues in the data. Close to half of all eligible patients for this service did actually have an office visit within 14 days of being discharged, so that didn't seem to be the largest barrier to being able to provide the service. We speculate that one thing that may be more difficult for physicians is to be in touch with patients within two business days after the discharge. That does not require a face-to-face visit. It just means that someone from the office practice is following up with the patient, doing medication reconciliation, finding out how the patient is doing at home, and trying to identify any problems.

Q: What are barriers to making that contact?

A: One might be the community-based physician who is following up with the patient may not have even known that the patient was discharged, so the communication from the hospital to the practice might undermine the efficiency. It may also be the community-based physician doesn't have the staffing or workflow to actually do that follow-up in a short turn-around time.

To provide this service does involve some changes in a practice that might be geared up, as most practices are, for who is coming into the office that day for a face-to-face visit. It also involves multidisciplinary teams. It isn't to say that a physician could not be calling the patient after they're discharged, but in many cases, I think this is a role that either a nurse or a pharmacist or other health professional could do effectively.

Q: Do the results of this study prove that practices should implement such systems?

A: It's possible that some of what we are observing has to do with the kinds of providers and patients who were receiving the service as opposed to all possible patients who could have gotten it. The study does use a lot of statistical techniques to try to adjust for that potential bias, so we do feel quite confident and we do think the results suggest there are real health and cost savings associated with the intervention. We think that it would be appropriate to try to find ways to make the use of the service more widespread.

Q: What might be some ways to do that?

A: The amount of payment for the service relative to an office visit is, on average, about $40 higher than a regular visit. While that's definitely a benefit, we wonder if it's enough to entice more physicians to make the investments they need to make in their practice. We think it might be appropriate for CMS to re-evaluate whether a higher payment amount would be appropriate for the service, given especially that it is associated with overall cost savings for the Medicare program. We also think that the billing period of waiting 30 days after the service is first implemented might be a little bit excessive and might be a barrier.

Q: What lessons should hospitalists take from this research?

A: It really shows the role of the community physician working in concert with hospital-based physicians to be able to achieve the goals of reducing readmissions and improving health outcomes. To me, it's a little bit the equivalent of a quarterback and a receiver. If the hospitalist is the quarterback who is throwing the pass or discharging the patient from the hospital, there needs to be good communication with the receiver on the other end, the community physician who is receiving that patient.