When I was a boy, I saved box tops for a secret decoder ring.
Recently I had occasion to think about the health care analog to secret codes and decoders -- the CPT codes (current procedural terminology) used to describe and bill for health care services and the associated Medicare payments that shape health care for older Americans.

On this particular occasion I was at a meeting at AARP, part of our grant, Professional Partners Supporting Family Caregivers, and the discussion turned to how to pay physicians for the time we wanted them to spend educating and counseling family caregivers. (Helping family caregivers take better care of their loved ones and themselves is a key issue to helping older adults stay at home as long as possible while maintaining quality of life for everyone.)

As in so many complex, yet low tech, services that older adults need (e.g., care coordination, geriatric assessment, or end-of-life planning) the issue boils down to one of dollars and time. It is very hard for physicians to allocate enough time to these services or even hire other staff to do so, if the services don't have a direct, additional fee-for-service payment attached to them.

Medicare is not a very good payer for outpatient primary care services in general -- simple bread and butter things like diagnosing changes in chronic conditions and modifying medications or other treatments. But most physicians can do those things quite quickly and so they can afford to have a reasonable percentage of Medicare beneficiaries in their practices. Unfortunately, the more complex and time consuming services are also billed using the same Evaluation and Management (E&M) codes that cover most other primary care services in the office.

Physicians will often say that Medicare doesn't "cover" care coordination or patient/family education. This is not true. Those are covered benefits. But Medicare considers them as part of the services that are included with the diagnostic and prescribing functions that are already being reimbursed as part of evaluation and management, not separate services. And the evaluation and management services are so poorly paid that most providers simply could not afford to stay in business if they spent a great deal of extra time providing them.

Looking at the evaluation and management service guide on the Medicare website suggested an interesting comparison. It suggests that diagnosing and prescribing an antibiotic for an earache is a relatively simple matter, a level 1 E&M code. If we plug the code for an office based visit with an established patient for such an episode (99211) into the magic decoder that Medicare provides on its website, we find that Medicare would pay between $16.65 and $24.71 depending upon where you were in the country (variation is intended to reflect differences in labor and insurance costs). The guide also suggests that this would be the payment for a 10 minute visit. (For that very service for my four year old daughter, taking no doubt less than 10 minutes, my PPO insurance paid $76 in 2008.)

As the complexity of the review of the complaint, physical assessment, review of organ systems, and family/social history, and decision making get more complicated, the payment does rise. But so does the time to do all that work and to document it. A top intensity visit, a level 5, with very comprehensive assessment that the guide describes as taking an hour of face to face time, would pay $124.79 and still not provide enough money to make it work to take additional time yet to educate a family member, call other physicians to harmonize treatment plans, or convene a family for an end-of-life discussion. Moreover, as the code level and payment increases, so too does the chance of the claim being rejected or audited.

At the same time, we should all be aware that the US pays a higher share of GDP for health care than any other advanced nation and gets worse outcomes for it. In good conscience I don't think that one can advocate for just spending more money unless it comes with some assurance that the spending will be offset by savings elsewhere and return more value to the health of the public. Reliance upon fee-for-service payment alone is not a viable path for improving health care services to older adults and their families.

This is a very complex topic that generates pretty heated controversy in every discussion among experts I have ever witnessed, so I welcome any feedback that readers might have.