In an April 11 testimony before the U.S. Senate Committee on Finance, University of Pennsylvania Professor Amol Navathe, MD, PhD, said that Medicare’s current fee-for-service system is a key factor in producing fragmentation in care, particularly for patients with multiple chronic care conditions.

“The focus isn’t on producing more health, just on producing more health care. Each clinician has their head down, focused on doing more visits and procedures, while the critical task of coordinating care often gets overlooked,” he emphasized.

Vice Chair of MedPAC

Navathe is a Senior Fellow at Penn’s Leonard Davis Institute of Health Economics (LDI) and Vice Chairman and Commissioner of the Medicare Payment Advisory Commission (MedPAC), a non-partisan agency that advises the U.S. Congress on Medicare policy. He was one of four top national experts testifying before the “Bolstering Chronic Care through Medicare Physician Payment” hearing in the Dirksen Senate Office Building.

The core of Navathe’s remarks were focused on Medicare’s lack of a well-organized and adequately funded system enabling primary care physicians to consistently provide effective overall care coordination for beneficiaries with multiple chronic conditions.

“Fragmentation plagues chronic disease care,” Navathe said. “Medicare beneficiaries with chronic conditions see more than five physicians concurrently. He pointed to the findings of Penn colleague, LDI Senior Fellow, and primary care physician Matthew Press, MD, MSc, that underscore the challenges and potential communications breakdowns in this type of multiple-provider care.

Animating the Issue

At a 2018 health care conference, Press gave a presentation on his work that was recorded on video by LDI. It detailed the case of a 70-year-old patient with multiple chronic medical conditions who came in with an infected kidney stone. The workup on that ailment also found that the patient had cancer of the bile ducts.

In the subsequent three months, Press documented his coordination of the patient’s care. It included engaging with 11 other clinicians, including 12 calls and 28 emails back and forth with them related to 11 patient appointments that ultimately involved five procedures. To visualize the communications complexity of this single typical case, Press created an animated illustration covering the period from the patient’s first visit to the day when the oncologist reported to him that the tumor was out. The animation resembles a wild tangle of colored spaghetti, with each strand being a communication of medical detail.

“It’s pretty astounding how much time and effort it takes to engage in more than 50 interactions with other clinicians and the patient to actively coordinate care for just one important clinical condition,” said Navathe.

CMS’s Warnings

The Centers for Medicare and Medicaid Services (CMS) has prominently published warnings about the potential dangers of not coordinating care properly across multiple providers:

“When doctors and other health care providers don’t communicate effectively with each other treatments prescribed by different doctors for a patient’s different health issues might conflict or become unmanageable for the patient. The patient is more likely to get unnecessary repeat tests. Worse yet, lack of coordination can lead to negative health outcomes for patients, more use of emergency care, medication errors, poor transitions of care from hospital to home, and medical errors. These effects can have a larger negative impact on chronically ill patients or patients with multiple complex health conditions.”

However, Navathe told the senators, CMS’ efforts to promote care coordination aren’t working because the agency’s own payment policies pose a formidable barrier to achieving that goal.

“Ticky-Tacky” Efforts

“With good intentions CMS has attempted to fill this [coordination] gap by adding more billing codes but reducing the important work of clinicians to a list of codes is a fraught task,” Navathe said. “The result is an administratively complex system of ticky-tacky codes that are underused because the cost of billing them is itself unprofitable. For example, the administrative cost to bill for a visit is about $20. That’s more than the $15 physicians get paid for a virtual check-in visit.”

“Addressing fragmentation will require a new way of delivering chronic disease care, which in turn will require substantial changes to physician payment,” Navathe continued. “Simply adding more dollars to the current system won’t be enough. Physician groups need to be able to invest in new capabilities, use technologies like telehealth when safe, efficient, and effective, and staff practices differently. A natural place to start is investing in primary care. One promising path is to provide primary care physicians with steady monthly payments per beneficiary, in addition to certain fee-for-service payments.”

“This would balance the goals of preserving access while enabling primary care physicians to practice more patient-centered care. An additional benefit would be unshackling primary care physicians from a system that requires billing for each and every task.”

CMS Advisory Panel Needed

Navathe emphasized the solution to the overall problem requires changing and improving CMS’ physician payment policies. He said such an effort would benefit from the input of multidisciplinary experts who could be convened as an advisory panel to CMS.

Senate Committee Chair Ron Wyden (D-OR) told Navathe, “I like your idea very much because we’ve been talking about what to do about traditional Medicare for ages. So, we’re going to want to get more details from you about how to do that with your idea of the per-month, per-patient kind of payment for care coordination.”

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