Aetna makes it official: no more bundling of E/M codes

Marking a small victory for physicians, Aetna recently announced that it would stop bundling evaluation and management (E/M) codes submitted on the same date of service. As of Feb. 6, the insurer will now reimburse physicians for both a problem-focused E/M service (e.g., 99201-99205 or 99211-99215, billed with modifier -25) and a preventive E/M service (e.g., 99381-99387 or 99391-99397) provided on the same date. Aetna will also reimburse physicians for an E/M service (billed with modifier -57) performed in conjunction with a major (global, 90-day) procedure.

Physicians may resubmit affected claims for services that were delivered no more than 180 days prior to Feb. 6, provided the original claims were submitted within the timely filing period defined by their contract with the health plan. No interest or penalties for late payments will apply to these claims.

As reported last month in FPM, the AAFP sent a letter to more than 40 insurers in December requesting that they follow Aetna’s lead. So far, no other insurers have announced similar changes.

Medicare pilot uses care coordinators to manage patients' chronic disease

The Centers for Medicare & Medicaid Services (CMS) has enrolled more than 100,000 beneficiaries in a pilot program (Medicare Health Support) intended to improve the management of chronic diseases and reduce costs. CMS has contracted with eight companies that will provide care coordination for a monthly fee. The companies will have to refund a portion of the money unless they can demonstrate improved patient outcomes and reduced costs.

Some believe the program takes the wrong approach. “By paying other people to … coordinate care, Medicare is adding an unnecessary layer of extra bureaucracy and expense in a system that needs to help underwrite better functioning physician practices,” says Christine Cassel, chief executive of the American Board of Internal Medicine, in the Feb. 8 Wall Street Journal.

The AAFP and the American College of Physicians believe primary care physicians should be paid a care management fee for providing these services.

Internists predict “impending collapse of primary care”

“Primary care is on the verge of collapse. Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy,” according to a recent report from the American College of Physicians (ACP). The key contributors to the problem are “inadequate and dysfunctional payment policies,” says the report.

The report proposes that primary care physicians redesign their practices around the idea of an “advanced medical home” and that payers reward practices certified as such with “new models of reimbursements to provide financing commensurate with the value they offer.” (To read more about the “advanced medical home” concept, visit http://www.acponline.org/hpp/statehc06_5.pdf. It is similar to the New Model of family medicine outlined in 2004 in the Future of Family Medicine report, which is available at http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.)

The ACP report also calls on policy-makers to reform Medicare reimbursement by paying more for evaluation and management services, preventive care and time spent outside the face-to-face visit coordinating patient care. It also calls on Congress to repeal the flawed “sustainable growth rate” formula, which results in annual cuts in physicians’ Medicare payments.

“Unless immediate and comprehensive reforms are implemented by Congress and CMS, primary care – the backbone of the U.S. health care system – will collapse,” concludes the report. “The consequences will be higher costs and lower quality as patients find themselves in a confusing, fragmented, over-specialized system in which no one physician accepts responsibility for their care, and no one physician is accountable to them for the quality of care provided.”

EHR adoption could be slower than expected

While the Bush administration has set a goal to have an electronic health record (EHR) for every American by 2014, full EHR adoption could take years longer. A recent study published in the Journal of the American Medical Informatics Association found that small medical offices (those with 10 or fewer members) are not likely to adopt EHRs quickly. The report predicts that, under conservative estimates, 87 percent of small practices will be using EHRs by 2024.

FPs implement new approaches to care

A recent AAFP survey asked family physicians whether they have embraced any of the following new technologies and other strategies in their practices. “Personal digital assistants” were the most prevalent, while “group visits” were the least.

Legal opinion supports FPs who perform endoscopic procedures

After the American College of Gastroenterology (ACG) sent a letter and legal opinion to hospital administrators, cautioning them about granting gastroenterology privileges to physicians who are not board certified in gastroenterology, the AAFP recently countered with a dissenting legal opinion (available at https://www.aafp.org/x40631.xml).

In a letter to hospital administrators, AAFP Board Chair Mary Frank, MD, wrote, “It is unfortunate that the ACG has apparently chosen to subordinate the health and welfare of the public to its own self-interest by preventing competent physicians from performing potentially life-saving procedures for their patients by attempting to scare hospitals and peer review participants into denying qualified physicians privileges.”

The legal opinion obtained by the AAFP states, “the law is straightforward and clear that credentialing decisions may lawfully be based on the demonstrated competence, experience and training of the practitioner. This is the law now and was the law over 10 years ago when the ACG first communicated its attack on the grant of endoscopy privileges to family physicians.” It concludes that hospitals and peer review participants risk liability if they base their privileging decisions on other factors, and physicians who join together “to refuse to provide surgical or other backup to family physicians or to exclude family physicians from practice, may be engaged in a group boycott constituting a violation of antitrust laws.”