Penny Wise, Pound Foolish

What drove me crazy about practicing medicine in a nursing home wasn’t the patients, although with their many medical problems often including cognitive impairment they were a challenge; and it wasn’t the families, though with their anxiety and attentiveness and sometimes their guilt they were an even greater challenge. What drove me crazy about nursing home medicine was Medicare billing.

When I saw patients in the nursing home, I was hemmed in by the fact that Medicare had a very clear idea of what constituted an appointment with a nursing home patient. According to Medicare, a “visit” (billing jargon) entailed a face to face “encounter” (more billing jargon) between a “clinician” (in this case, me, the physician) and the patient.

Once the patient and I were in the same room, I had a script to follow. I was first supposed to take a “history,” (medicalese for eliciting symptoms); then I was supposed to do a physical exam, which involved specified “elements” (examination of particular bodily parts). Finally, I was supposed to engage in “evaluation and management,” which might result in ordering lab tests or prescribing a medication. The problem was that in the nursing home environment, a history and physical, to be useful, looked very different from what Medicare had in mind. Many of my patients were demented and couldn’t possibly give a coherent history. Moreover, many of those who had relatively mild dementia could always be counted on to complain about something, so if it had been up to the patient, I would have made a visit every day. Many of the patients had medical conditions that required observation over a prolonged period, not just at one point in time. For example, a patient with dementia might have paranoid delusions that significantly affected his or her quality of life, but those delusions would come and go. A patient with Parkinson’s disease might have difficulty walking that fluctuated over the course of the day, depending both on random changes and on when the patient last took medication. As a result, the most meaningful history and the most useful physical observations had to be obtained secondhand—from nurses, nurses aides, and other staff members including physical therapists and social workers. I spent much of my time interviewing personnel about my patients, time that Medicare did not recognize as valuable because it was not part of an “encounter.”

Starting in January, 2015, Medicare will pay a special monthly “complex chronic management” fee on top of the usual reimbursement to primary care patients who care for patients in the office. But somehow the nursing home environment is assumed to be immune from the need for this kind of supplementary support. Calls to family members and discussions with other members of the interdisciplinary team are supposed to be part of the “evaluation and management” services that are “bundled” into the Medicare fee schedule. So it’s thought to be perfectly reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide documentation that he or she has taken 2 out of 3 possible steps: obtained a detailed history, performed a detailed physical exam, or engaged in “moderately complex” medical decision making. Only if the physician takes a comprehensive history, performs a comprehensive exam, and engages in highly complex medical decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136. For comparison, note that a gastroenterologist is paid on average $220 for performing a colonoscopy, a 20-minute procedure. 

No wonder physicians often respond to a call from the nursing home about a sick patient with an order to send the patient to the hospital for evaluation. Send a frail nursing home patient to the emergency room and he has, I would guess, about a 90% chance of being admitted. So instead of paying a physician an appropriate amount for making a visit to the nursing home and instituting on-site medical care, Medicare would fork out a minimum of $5774 (the base DRG payment) for a 5-day hospitalization, exposing the patient to the risk of iatrogenesis. Does this make any sense?