Coordinating the Coordinating Fee

You may have heard CMS has posted a proposed rule for modifying physician pay–for both specialists and primary care docs:

Up for increases:

• 7% for family physicians
• 5% for internists
• 4% for geriatricians

“Most of this increased reimbursement would result from a separate payment that Medicare would make to physicians for coordinating a patient’s care for the first 30 days after discharge from a hospital, skilled nursing facility, or certain outpatient services. The fee, which will have its own procedure code, reflects the Obama administration’s push to reduce hospital readmissions caused by sloppy follow-up care. At the same time, the administration has made it an overall priority to improve reimbursement for primary care services, according to CMS.”

How is this going to square in a budget neutral environment?  Here is where it gets tricky:

You can bet the specialty societies of all these groups will have something to say–after all, they all contribute value to the system…me thinks.  The question now is who contributes more?

Another thing to watch are comments relating to the definition of a coordination fee, i.e, what service qualifies for payment and how do you characterize it.  Additionally, and most urgently, how do you parse the payment if both the hospitalist and community provider (or geriatrician) participate in the discharge transition.  That is assuming hospitalists are eligible for the payment of course (I would think yes).

Want more?  Is there one payment only for a 30-day period (readmission at a second hospital or for unrelated DRG); do surgical discharges qualify in co-management situations (bundled fee); will volume and intensity of specialty services change to maintain the aggregate status quo; and how will these increases fare in a risk integration/ACO type model and will this payment paradigm stick?

Regardless of the details, Cassandra is no longer calling and the pincers may be starting to squeeze.

UPDATE: Just giving this some back of the envelope thought, if an internist boosts their salary, say, 3-4% based on the coordination fee (internists are up for a 5% boost in total), how much will the fee pay, and how many “coordinations” is CMS anticipating per doc.  If an internist earns $200K and they boost to $206K, is that 75 transitions at $80/case?

Is the fee properly valued?  What does one hip replacement pay? Given the work volume anticipated, and assuming lack of remuneration is partly responsible for the current transition gaps (its work after all), is $80 appropriate and will it alter transition activity significantly and increase physician participation.  P4P suffered the same fate.  Due to burdensome documentation along with poor reimbursement and mismatched intensity, engagement was low.

UPDATE#2: Good table and review in AMA news.