Many nursing home COVID-19 patients would have benefitted from daily, reimbursed-for physician visits in their skilled nursing facilities, but they were not entitled to them.
With an epic crisis still at hand, the quickest way to improve performance and public perception of nursing homes is to introduce daily covered visits.
Astonishingly, Medicare and Medicaid suggest that an attending physician visit skilled nursing patients only once every 30 days, generally limiting coverage to that amount. CPT attending codes 99307-10 reimburse approximately $85-$126 for physician follow up visits, depending on the geographic region. Medicaid’s physician reimbursement rates are far lower than Medicare’s physician payment. In California, for example, Medicaid pays a doctor approximately only $38 per monthly skilled nursing center visit.
Medicare and Medicaid physician visitation frequency and reimbursement fees are woefully inadequate.
Comparing visits over time
The 30-day governmental allocation for physician visits is a relic of the old 1970s model for skilled nursing centers, when residents were predominantly chronic, long-term patients, at low-activity levels, with few changes of condition. By contrast, today the SNF patient population is increasingly at a high-need level. These SNF patients require complex care, as demonstrated by their PDPM scores.
In the 1990s, many of these patients would be at acute hospitals, given their comorbidities. Although patient needs have grown complex, Medicare reimbursement for physician visits remains fixed at only once for each 30-day period.
An acute hospital Medicare reimbursement — the basis for a standard of practice — calls for daily physician visits and the primary driver of patient care is a physician. On the other hand, in skilled nursing, when physicians do not see patients as frequently, more responsibility falls upon nurses. To improve care, Congress or the Centers for Medicare & Medicaid Services need to authorize daily skilled patient physician visits, at the same frequency and reimbursement levels as physician visits in acute hospital settings.
ACOs already allowing daily visits
Notably, managed-care IPAs and ACOs recognize the importance of daily physician visits for nursing home patients. For example, Healthcare Partners, a managed-care pioneer, acquired by OPTUM, initiated a model calling for staff physicians to see each SNF patient on skilled level services on a daily basis as early as 1992.
The Healthcare Partners model has two distinct advantages. First, daily, on-site physician visits can prevent potentially unnecessary hospitalizations. Second, daily physician intervention does result in shorter patient length of stay and improved outcomes.
Other leading IPAs such as Regal Medical/Heritage have already adopted these practices. Medicare ought to similarly adopt these practices.
Some sophisticated physicians successfully bill for visits several times per month on new admits by identifying change of conditions or creating new face sheets based on secondary diagnosis. While guidelines appear to allow billing in some instances more often than monthly, as a practical matter, doctors have difficulties ever collecting from intermediaries for these extra visits.
The standard medical and billing practices are still based on the monthly visits, particularly for Medicaid patients, who constitute the overwhelming majority of patient census. Some nonprofits and select facilities already have a single staff physician who sees all patients as needed, but even these models would vastly benefit if Medicare and Medicaid reimbursed for such daily visits.
As veteran hospitalist Mohamad Faruki, M.D., of Orange, CA, explains, “During the COVID-19 surge in California, we had no space at the acutes. We successfully provided treatment for patients in skilled nursing facilities, with the same protocols we would have utilized in the acute, except that we were not paid for daily visits. If we could initiate daily visits and be reimbursed for them, we could save Medicare considerable resources and funds by reducing LOS and preventing rehospitalization.”
Medicare and Medicaid already allow daily visits for LTACHS and sub-acutes
Daily physician reimbursement for visits outside the acute hospital is already allowed in some settings. Physicians can bill for daily patient visits at LTACHS. Many patients’ medical profiles at LTACHS closely resemble those of complex patients at skilled nursing centers, leading to incongruous results.
For example, doctors are paid daily by Medicare to visit their ventilator-dependent patients at an LTACH, but only once per month for ventilator-dependent patients at a skilled nursing center. Skilled nursing centers serving complex patients deserve to stand on equal footing with LTACHs. Skilled nursing facilities should also be entitled to reimbursement for daily physician visits, at least for high-need patients.
Another context where physicians are reimbursed for frequent visits is under state Medicaid subacute programs. In California, skilled nursing centers can contract with Medicaid for care of subacute, such as complex tracheostomy or ventilator-dependent patients. Under these programs, Medicaid requires pulmonologist visits several times a week during the initial 30 days after admission and at least weekly intervals thereafter. These specialized programs acknowledge the great value of frequent physician interventions. They recognize daily physician visits pay for themselves by shortening lengths of stay and reducing hospital readmissions.
Daily visits will improve COVID-19 care
Enhanced physician involvement in skilled nursing centers will also raise educational levels and promote learning opportunities for front-line nurses. Importantly, infection control practices and treatment of early-stage COVID-19 disease would dramatically improve. Increased physician visits will also help skilled nursing centers struggling with post-COVID occupancy declines improve their marketability and census, and protect facilities against baseless litigation.
Practical proposals for daily physician reimbursement
Practical proposals for payment of daily SNF physician visits can be implemented through four alternative options under which Medicare and Medicaid would:
- Pay for all daily visits for skilled level SNF patients at 80% of the allowable acute hospital fee schedule.
- Pay for all daily SNF visits for at least the first 30 days of a covered stay.
- Pay for weekly visits for all patients, including those at custodial levels.
- Pay for daily visits for all higher-level PDPM patients receiving skilled Medicare services.
Politically, the climate has shifted as to COVID-19 relief. The Biden administration appears less inclined to propose direct relief for providers than the previous Republican regime. Indeed, Biden’s $1.9 trillion relief bill largely did not include direct provider assistance. Hence, requesting additional funds for a third-party – not for skilled nursing operators – but for physicians, is an “ask” more likely to be granted.
Likewise, at the state level, the latest relief bill channels extra funding to Medicaid programs. Some of these new resources should be directed to physician SNF services. ACHA, Leading Age and consumer advocacy groups, as well as the American Medical Association, must unite and form a coalition together to encourage states, Congress and CMS to affirmatively respond: “Yes, the doctor is in.”
Kenneth Lehmann, J.D., is the founder and operating partner of an 11-facility skilled nursing chain with locations in Californica’s Orange, San Bernardino, and LA counties.