Inadequate reimbursement for care management to primary care offices.
BACKGROUND
Care management in primary care can be effective in helping patients with chronic disease improve their health; however, primary care practices are often challenged to identify revenue to pay for it. This study explored the impact of direct reimbursement on the provision of care management in a primary care physician organization.


METHODS
Using data on expenses and health plan reimbursement during the initial 16 months of care management implementation at 5 practices, we calculated the percentage of related costs that were covered by payments. Qualitative data from interviews with practice members were used to identify their perceived barriers to care management reimbursement and the impact of current reimbursement strategies on service delivery.


RESULTS
Direct reimbursement for care management covered only 21% of the costs. Reimbursement varied by care manager background, patient diagnoses, insurer, and indication for the visit. Barriers to gaining reimbursement included patient resistance to copay, clinician hesitation to bill for care management visits (for fear the patient may receive a bill), differential reimbursement policies of insurers, and general lack of reimbursement for care management in many cases. Although practice-level quality improvement incentives were an alternative means of supporting care management, because these incentives were not directly tied to the service of care management, they were used for other activities ultimately supporting patient care.


CONCLUSIONS
This study highlights the need for sufficient reimbursement to initiate and maintain care management for patients in primary care as proposed for service reforms under the Affordable Care Act.
From the Department of Family Medicine, University of Colorado Denver, Aurora, CO (JSH); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (ZL); Department of Nursing, Sienna Heights University, Adrian, MI (LA). jodi.holtrop@ucdenver.edu.
Jodi Summers
JS
Holtrop
From the Department of Family Medicine, University of Colorado Denver, Aurora, CO (JSH); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (ZL); Department of Nursing, Sienna Heights University, Adrian, MI (LA).
Zhehui
Z
Luo
From the Department of Family Medicine, University of Colorado Denver, Aurora, CO (JSH); Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI (ZL); Department of Nursing, Sienna Heights University, Adrian, MI (LA).
Lynn
L
Alexanders
D002908:Chronic Disease / Q000191:economics; D005102:Health Expenditures; D006801:Humans; D058991:Patient Protection and Affordable Care Act; D058007:Physicians, Primary Care / Q000191:economics*; D011320:Primary Health Care / Q000191:economics*; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States
Case Management; Health Policy; Practice Management; Primary Health Care