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Topics in Practice Management

Transitional Care Management Reimbursement to Reduce COPD Readmission Shreya Kangovi, MD; and David Grande, MD, MPA

Reducing preventable readmissions for COPD is an important national health policy goal. Thus far, Centers for Medicare & Medicaid Services (CMS) policies focused on incentivizing improvements in inpatient quality have had variable success. In its 2013 physician-payment rule, CMS announced new payments that reimburse ambulatory care providers for timely posthospital visits and transitional care management services. CMS hopes that posthospital transitional care and services will substitute for readmission, but the evidence supporting this hypothesis is mixed. In this article, we discuss ways for ambulatory pulmonologists to leverage transitional care management payments to enhance access for their patients with COPD while minimizing the risk of a paradoxic increase in readmission rates. CHEST 2014; 145(1):149–155 Abbreviations: CMS 5 Centers for Medicare & Medicaid Services; CPT 5 current procedural terminology; FTF 5 faceto-face; NFTF 5 non-face-to-face; SES 5 socioeconomic status; TCM 5 transitional care management

percent of all patients with COPD are Twenty-one readmitted within 30 days of discharge, and costs 1,2

for these readmissions are 18% higher than for initial stays.1 This high prevalence and cost make COPD an important target of Centers for Medicare and Medicaid Services (CMS) policies designed to reduce readmissions. Thus far, the CMS strategy for reducing readmissions has focused primarily on incentivizing improvements in inpatient care and discharge planning. For example, the Hospital Readmission Reduction Program penalizes hospitals with higher than expected rates of readmission for specified conditions. These inpatient-focused strategies have not produced consistent reductions in readmissions.3 One reason is that readmissions for many conditions, including COPD, are influenced by social and

Manuscript received April 1, 2013; revision accepted June 17, 2013. Affiliations: From the Philadelphia Veterans Affairs Medical Center (Dr Kangovi); Division of General Internal Medicine (Dr Grande), Perelman School of Medicine; and Leonard Davis Institute of Health Economics (Drs Kangovi and Grande), University of Pennsylvania, Philadelphia, PA. Correspondence to: Shreya Kangovi, MD, 13th Floor, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104; e-mail: kangovi@ mail.med.upenn.edu © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0787 journal.publications.chestnet.org

medical factors that are not immediately modifiable in the inpatient setting, such as income,1 insurance,4 and coexisting mental health diagnoses.5 In addition, patients may already perceive hospital care for conditions such as COPD as more accessible and of higher quality than ambulatory care.6 Therefore, initiatives that improve inpatient quality without making complementary improvements in ambulatory care could paradoxically drive patients further toward inpatient care and increase hospital readmissions. In its 2013 physician-payment rule, CMS announced new payment codes (99495 and 99496) that incentivize ambulatory care providers to participate in transitional care management (TCM).7 To bill for these payments, ambulatory physicians must provide three key services. First, they must make contact with patients within 2 days of hospital discharge. Second, they must have a face-to-face (FTF) visit with moderate or high complexity patients within 7 days to 14 days of discharge. Third, and perhaps most importantly, they must provide indicated care coordination services, although not necessarily in a FTF setting, during the 30 days after discharge (Table 1). The TCM codes are not restricted to any particular diagnostic category; however, they are restricted to patients discharged to home and may not be applied for patients discharged to a postacute care facility. TCM payments range from $164 to $231, up to $91 more than office visit CHEST / 145 / 1 / JANUARY 2014

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Table 1—Non-Face-to-Face Services Required for Transitional Care Managementa Non-Face-to-Face Services Provided by the physician or other qualified provider Obtaining and reviewing the discharge information Reviewing need for or follow-up on pending diagnostic tests and treatments Interaction with other qualified health-care professionals who will assume or reassume care of the patient’s system-specific problems Education of patient, family, guardian, and/or caregiver Establishment or reestablishment of referrals and arranging for needed community resources Assistance in scheduling any required follow-up with community providers and services Provided by clinical staff Communication with the patient and/or caregiver within 2 business days of discharge Communication with home-health agencies and other community services used by the patient Patient/caretaker education to support self management and activities of daily living Assessment and support for treatment regimen adherence and medication management Identification of available community and health resources Facilitating access to care and services needed by the patient and/or family aIn addition to these non-face-to-face services, transitional care management requires a face-to-face visit and medication reconciliation within specified time frames.

reimbursement ($73 to $143). There is no restriction on the use of additional office visits (ie, evaluation and management services) provided during the 30-day transitional service period. The majority of the TCM payments are expected to go to primary care providers, increasing their Medicare reimbursements by approximately 7%.8 However, TCM payments are not limited to primary care providers because of the belief of CMS that pulmonology, cardiology, or other specialty offices may sometimes serve as patients’ medical homes and provide those patients with the best transitional care. Rather than restricting TCM payments to a particular type of physician, CMS has opted to use a “first claim” system. CMS will pay the first (and only the first) physician or qualified nonphysician provider submitting a claim during the 30-day postdischarge transitional window. For example, a patient admitted with advanced COPD may identify his pulmonology office as his ambulatory medical home. The inpatient team would then be expected to notify the pulmonologist of the patient’s discharge, and the pulmonologist would then be in the best position to provide and submit the first claim for TCM services. In instances where a patient sees the same physician in the hospital and for follow-up, that physician is permitted to bill for both hospital discharge and care transition services. 150

CMS does not directly incentivize ambulatory care providers to keep their patients out of the hospital. Instead, CMS hopes that TCM payments will “provide better incentives to ensure that these patients are seen in a physician’s office rather than be at risk for readmission.”7 This statement, and the policy itself, contains an assumption: Increasing posthospital ambulatory care, in the form of visits and certain non-faceto-face (NFTF) transitional services, will lead to a reduction in readmission rates. While some studies suggest that timely ambulatory care and NFTF services can serve as a substitute for readmission,9-11 others studies have found that patients who received more intensive posthospital ambulatory care (including both office visits12 and NFTF services such as telemonitoring,13 proactive telephone follow-up,14 or enhanced communication between inpatient and ambulatory providers15) had unchanged or higher rates of hospital readmission. In reality, increases in posthospital ambulatory care driven by TCM payments will likely have dual effects.16 When TCM care prevents serious medical errors, through activities such as medication reconciliation,17 or allows patients to access care they would have otherwise sought in the hospital, it will lead to a reduction in readmissions. However, enhanced access may actually facilitate an increase in readmissions. Because TCM payments are restricted to patients with moderate or high complexity, ambulatory providers will selectively be caring for the sickest patients early in their posthospital recovery. Just as any screening test may lead to closer surveillance and higher rates of intervention, increased transitional care could lead to a greater number of referrals from ambulatory physicians back to the hospital. Whether the specific bundle of postdischarge services that this new payment mechanism incentivizes will reduce readmissions is an important question for future research and evaluation. TCM payments will directly reimburse pulmonologists for improving access and providing more care coordination services to patients with COPD during the posthospital transition. However, to prevent COPD readmissions, pulmonologists will also need to leverage additional revenue from TCM payments to take steps beyond the services the TCM payments directly incentivize. In this article, we suggest ways in which pulmonology practices can leverage the TCM payments to improve care for patient with COPDwhile minimizing the risk of a paradoxical increase in readmissions. Leveraging TCM Payments to Reduce Hospital Readmissions for COPD Improving Access Several published studies have highlighted difficulties that patients currently face in obtaining posthospital Topics in Practice Management

ambulatory care.11,18-20 In a retrospective cohort study of nearly 63,000 Medicare beneficiaries hospitalized with COPD, Sharma et al20 found that older age, black race, and lower socioeconomic status (SES) were associated with lower likelihood of ambulatory follow-up visit. Numerous studies have shown that patients with low SES are more likely to require repeated hospitalizations for ambulatory-care-sensitive conditions due to lack of access to outpatient care.21-24 CMS allows the TCM codes to be billed for either a new or an established patient. This will allow practices to initiate care for vulnerable patients who may have been hospitalized because they lacked an established outpatient provider. TCM payments require that ambulatory practice staff proactively communicate with the patient and/or caregiver within two business days of discharge and facilitate access to care, rather than waiting for patients to initiate contact. This may be particularly important for patients with low SES who have been shown to have lower levels of activation25 and various access barriers.18,19 In addition, TCM payments require that high complexity patients receive a FTF visit within 7 days and moderate complexity patients within 14 days of discharge. Therefore, providers will be incentivized to increase availability of appointments for patients early in their transition. For instance, providers may designate “flex” appointment slots for rapid scheduling of posthospital follow-up appointments. CMS was careful to note that the FTF visit need not occur in the office, but rather “can also occur at home or other location where the patient resides.”7 This provision means that physicians could bill for posthospital home visits to patients with limited mobility or access to transportation. In addition, many of the indicated care coordination services covered by the TCM current procedural terminology (CPT) codes, such as education or medication adherence support, do not require any FTF contact. This allows practices to provide services to patients in the manner that is most convenient and accessible to patients, such as via telephone or electronically. Prediction Rules for COPD Enhanced access will bring larger numbers of sick transitional patients into pulmonary practices soon after hospital discharge. To prevent this heightened surveillance from leading to an increase in readmissions, pulmonologists will need better guidance on indications for rehospitalization. Prior experience with prognostic scoring systems such as the pneumonia severity index (PSI)26 and more recently, the CURB-65 (confusion of new onset [defined as AMT ⱕ 8], urea . 7 mmol/L [43 mg/dL], respiratory rate ⱖ 30 breaths/min, BP , 90 mm Hg systolic or diastolic BP ⱕ 60 mm Hg, age ⱖ 65 y) and CRB-65 journal.publications.chestnet.org

(confusion of new onset [defined as AMT ⱕ 8], respiratory rate ⱖ 30 breaths/min, BP , 90 mm Hg systolic or diastolic BP ⱕ 60 mm Hg, age ⱖ 65 y)27 have reduced the number of low-risk patients with pneumonia who are hospitalized by 18% and have saved up to $994 per patient without decreasing quality of care.28,29 For COPD, such a risk score may be best used longitudinally, to compare patient’s level of illness at the time of discharge with their acuity at the time of posthospital ambulatory care. This is especially useful in an environment when fewer ambulatory pulmonologists are able to see their patients during hospitalization. An objective score trend may help pulmonologists gauge their patient’s clinical trajectory during the posthospital transition and may provide reassurance that a symptomatic patient is on the expected path of convalescence. Preparing for Higher Acuity Ambulatory providers will need to be able to accommodate those transitional patients who do not warrant immediate referral back to the hospital, yet require some immediate care. Larger practices that serve a sicker case-mix of transitional patients with COPD may invest in resources necessary for higher levels of care such as onsite radiograph facilities, respiratory therapy, or an observation care unit. Although the TCM CPT codes do not directly incentivize these investments, costs may be offset by increased practice revenue from TCM payments and billing for observation care. Observation care is as “ongoing short-term treatment, assessment, and reassessment that is furnished while a decision is being made regarding whether patients will require treatment as hospital inpatients.”30 Although observation units are typically attached to hospital EDs, observation care can also be provided in ambulatory clinics and is billed as an outpatient service.31 An ambulatory practice that can perform a radiograph to rule out pneumonia, provide onsite respiratory therapy, or observe for several hours a recently discharged patient with COPD may be less likely to route patients back to the hospital. In addition, for practices to deal with the higher level of acuity inherent to transitional care management, they will need to create care coordination systems. For example, a pulmonology office seeing a patient with COPD after hospitalization may need to arrange a same-day CT scan to rule out pulmonary embolism as the cause for residual shortness of breath and obtain consultation from a patient’s endocrinologist regarding hyperglycemia. Coordination of these services can occur through human systems (eg, a care coordination nurse or scheduler), physical colocation of services (eg, radiology), or electronic linkages (eg, electronic medical record communication with patients’ other providers).32 CHEST / 145 / 1 / JANUARY 2014

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Addressing Psychosocioeconomic Issues Clinical strategies alone may be insufficient to improve health and reduce readmission among the many patients with COPD who face serious psychosocioeconomic issues.4,33,34 In the past, practices may have taken a passive approach, labeling patients who did not engage in recommended posthospital ambulatory care due to psychosocioeconomic barriers as being “noncompliant.” Current fee-for-service payment structure incentivizes this passive approach: There is a high opportunity cost of proactive care for “noncompliant” patients relative to other patients. However, since vulnerable patients are the most likely to have poor posthospital outcomes and to require transitional care, practices will need to engage this population for TCM payments to have their intended effect. TCM codes will pay for practice staff to conduct outreach for education and coaching on self management. This type of health coaching is supported by evidence: A multicenter, randomized controlled trial of COPD self-management strategies reduced hospital admissions for exacerbation of COPD by 39.8%.35 Practice staff will also be required to identify available community resources that can help address patients’ underlying psychosocioeconomic barriers to self management, such as depression, transportation, and insurance difficulties. Community health workers,36,37 social workers,38 or nurse navigators39 have served these functions in various initiatives. Finally, evidence suggests that patients with end-stage COPD receive inadequate counseling on end-of-life issues and palliative care.40 A recent hospitalization may serve as a signal for both patient and pulmonologist that these services are warranted, and could create a path away from multiple unwanted readmissions. Redesigning Resource Allocation Within the Practice A systematic review concluded that ambulatory practice redesign based on elements of the chronic care model41 can successfully reduce emergency/unscheduled visits and hospitalizations for COPD (relative risk, 0.58 and 0.78, respectively).42 Currently, resources in most practices are not allocated to optimize care coordination, proactive panel management, or the use of NFTF services that are required for effective transitional care. This is especially true of specialty practices that have typically not benefited from primary care or patient-centered medical home demonstration projects. The new TCM payments may incentivize these specialty practices to engage in redesign. Practices may use risk stratification to allocate human resources efficiently within a practice. High-risk patients who have frequent hospitalizations may be assigned to physicians’ panels, while low-risk patients are managed by qualified nonphysician providers such as 152

nurse practitioners. This division could allow physicians to reduce panel sizes and expand the time allocated for inperson visits, allowing for time-consuming and often complex activities required for TCM payments: reviewing discharge summaries, performing medication reconciliation, coordinating decisionmaking with other providers, following up on inpatient tests, and updating the medical record with a current care plan. A similar strategy was the cornerstone of Group Health’s patient-centered medical home redesign, which resulted in a 29% reduction in ED visits and 11% reduction in ambulatory-sensitive-care admissions.43 Additionally, practices may optimize their use of NFTF activities. Schermer et al44 raised the concern that FTF follow-up visits may not be necessary or cost effective for the majority of hospitalized patients with COPD. While the TCM codes currently require a FTF visit, CMS has signaled that this requirement may be a temporary strategy to help beneficiaries understand why they are being charged a TCM copayment and reduce the risk of fraudulent billing. Ambulatory practices may choose to invest in evidence-based NFTF approaches such as provision of education and 24-h telephone support to high-risk patients.45 This strategy was found to reduce admissions by 45% and bed days by 37%, though the study was limited by its pre-post design. While telemonitoring approaches have shown mixed results,13 some studies46,47 have shown a benefit in a population of patients with COPD. Challenges and Future Directions Implementation of TCM payments will create several challenges. Ambulatory providers often have difficulty knowing when their patients have been admitted to the hospital. Discharge-day management CPT codes that reimburse inpatient providers for coordinating care with community physicians have been in place since 1996. Yet, in a systematic review of discharge communication,48 only 3% of primary care physicians reported being involved in discussions about discharge,49 and 17% to 20% reported always being notified about discharges.50,51 CMS hopes that discharge notification will improve as providers shift toward electronic health record systems, but this remains a future goal. The lack of a streamlined discharge notification system may be especially problematic given the “race-tobill” that may be triggered by TCM payments operating by a first-claim system. Presumably, multiple ambulatory providers for a patient may want to be the first to provide and bill for TCM services. CMS argues that it is unlikely that multiple providers will meet the requirements of TCM care, such as initiation of contact with patients within 2 days of discharge; meeting Topics in Practice Management

these requirements involves practice redesign, an opportunity cost that may not be worthwhile for all practices. While this is probably true, the provider who meets the requirements and submits the first claim for any given patient may not always be in the best position to coordinate comprehensive care for the patient in the long term. Avoiding this type of fragmentation requires that hospital providers notify the patient’s medical home of each discharge and help to facilitate early follow-up in that setting. This raises larger questions regarding the choice of a medical home for patients with conditions like COPD. Comparative effectiveness trials, such as the recent study by Chai-Coetzer et al52 of sleep apnea outcomes, that compare primary care vs pulmonary ambulatory care management would help inform this discussion. Regardless of where transitional care occurs, its success will largely depend on the challenging process of ambulatory practice redesign. Redesign for TCM payments will entail grappling with philosophical questions. For instance, how much should ambulatory practices invest in higher acuity care before becoming inefficient? It also involves a variety of logistical changes. For example, the TCM code is required to be billed at the end of the 30-day service period, not on the day of the office visit. This will require a change in billing systems. Evidence from studies of primary care redesign suggests that key elements in this process include tailoring redesign based on local needs assessment and building in an iterative process of implementation and evaluation.53-57 Finally, it will be important to define outcome measures for success of the TCM codes. Certainly, hospital readmission rates appear to be a metric of interest to CMS. Yet, there is a possibility that the TCM codes could improve health outcomes and the patient experience without reducing (and perhaps even increasing) readmission rates. Readmissions are a proxy for cost, which is undoubtedly an important element of health system performance. However, policymakers should take into consideration the other aspects of the “triple aims”58: reducing costs, improving the patient experience of care, and improving the health of populations. The new TCM codes compensate ambulatory providers for performing activities, such as postdischarge medication reconciliation and laboratory test follow-up, that will likely reduce medical errors. As such, medical error rate may be an important success metric for TCM codes and should be included in future studies. Conclusions Despite some challenges, the TCM codes represent a major step toward a more integrated health-care system. This billing structure will reimburse ambulajournal.publications.chestnet.org

tory pulmonologists for providing additional services to their patients with COPD during a highly vulnerable time. In addition, it may spark a process by which pulmonologists are able to redesign ambulatory care for the patient with COPD and move toward achievement of some, if not all, of the triple aims. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Transitional care management reimbursement to reduce COPD readmission.

Reducing preventable readmissions for COPD is an important national health policy goal. Thus far, Centers for Medicare & Medicaid Services (CMS) polic...
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