Coordinated care leads to bundled payments

Coordinated care is by no means a new concept or recent buzzword but it does flag some important developments in the ongoing transformation of health care. In our discussions with eye care providers it is not yet apparent that many have grasped the significance of press releases like the one on June 6 from CMS entitled, “CMS Announces Private-Sector Commitments to Improve Primary Care for Patients, Save Money for Medicare: Eight States will test unique investment in coordinated care”. 

“In a strong show of support for more effective, more affordable, higher quality health care, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to give more Americans access to quality health care at lower cost.”

The announcement goes on to explain a new initiative that impacts the business of every eye care provider from coast to coast, even though it specifies pilot projects in only eight states. Why is this important to you as an ECP? Because pilot projects like these signal ubiquitous change. If we understand the big picture, we can see that coordinated care spells the eventual demise of fee-for-service care billed directly by you to CMS or any other payer. To the extent that you don’t bill much to CMS, look past Medicare and Medicaid. See the private-sector commitments and public-private partnerships. Ubiquitous change.

“Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services. Simultaneously, participating commercial, State, and other federal insurance plans are also offering an enhanced payment to primary care practices that provide high-quality primary care. 

"We know that when we support primary care, we get healthier patients and lower costs," said Acting CMS Administrator Marilyn Tavenner, "This initiative shows that the public and private sectors can come together to meet the critical need for these services."

Insurers in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Oklahoma signed agreements with CMS to participate in this initiative. The markets were selected based on a diverse pool of applicants from commercial health plans, State Medicaid agencies, and self-insured businesses who hoped to work alongside Medicare to support comprehensive primary care. 

In order to receive the new care management fee from CMS and insurers, primary care practices must agree to provide enhanced services for their patients, including offering longer and more flexible hours, using electronic health records; delivering preventive care; coordinating care with patients’ other health care providers; engaging patients and caregivers in managing their own care, and providing individualized, enhanced care for patients living with multiple chronic diseases and higher needs. 

Approximately 75 primary care practices will be selected to participate in the Comprehensive Primary Care initiative in each designated market ...

The Comprehensive Primary Care initiative is a four-year initiative administered by the Innovation Center. Applications will be accepted until July 20.

For more information, please go to: http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html”

Takeaways for you as an independent eye care provider:

1. Getting connected with primary care is imperative to the survival of your business.
2. Coordinated care management fees mean that qualified entities will take over the complete care of the patient, including assigning their eye care provider.
3. Enhanced services include using EHRs, delivering preventive care (that’s you!) and coordinating care with patients’ other health care providers (that’s team-based care).
4. Chronic care is defined as two back-to-back billings by a provider for the same condition or diagnosis (that’s everyone, all your patients in due course).
5. Coordinating care with other health care providers means electronic communications … exchanging CCDs and other forms of patient information.
6. The National Eye Care Communications Project is focused precisely on helping you meet these requirements. 
7. The CMS Innovation website is a tremendous resource for understanding where the transformation of healthcare is taking us. We strongly recommend that you go there and read up on ACOs, Bundled Payments and the Comprehensive Primary Care Initiative. Links to all three topics are available in the bottom section of the home page.
8. Join us next day for more on the logical conclusion of coordinated care ... bundled payments.

Alistair Jackson, M.Ed.

Jim Grue, O.D.