September 19, 2007 (Washington, DC) - One way heart-failure disease management programs streamline care is to have a lot of it take place over the phone, potentially avoiding extra clinic visits and perhaps even some hospitalizations. And the extra telephone time that takes doesn't cost anything--at least, that's the misconception built into Medicare reimbursement schedules, according to investigators who are arguing for changes [ 1].
The current system, which accounts for follow-up telephone time within reimbursement for the clinic visit itself, "is fine for the usual phone call at a regular cardiology clinic, where it's usually only a couple of minutes," Dr Monica R Shah (Washington Hospital Center, Washington, DC) told heart wire .
But in disease management programs, calls are more frequent and less likely to be about renewing prescriptions than about symptoms or adjustments to therapy, according to Shah. "It's a cheap intervention. But it's not a procedure or a billable service, so it's hard for people to understand that there's a lot going on during these telephone calls."
Most large heart-failure clinics, she said, are caring for 500 to 600 patients at a time, with one or perhaps two nurses handling the phone calls. "These calls are taking an average of six to eight minutes, and you have to make multiple calls per patient. So over time, it really does add up."
In an analysis of 130 patients participating in three such programs, a prospectively defined substudy of the randomized STARBRITE trial, much of the care over a four-month period took place over the phone. It was during that time that about 42% of cases of volume overload were identified, more than half of diuretic dosing changes and about 30% of beta-blocker adjustments were made, and more than half of patient education was conducted, reported Shah at the Heart Failure Society of America 2007 Scientific Meeting.
Primarily a comparison of outpatient care guided by brain-type natriuretic peptide (BNP) testing vs conventional clinically based management in patients recently discharged after an episode of acute decompensation, STARBRITE showed no significant differences between the two strategies. There were signs, however, of improved used of ACE inhibitors and perhaps beta blockers among patients managed according to BNP levels. Shah had presented those findings at the American Heart Association 2006 Scientific Sessions; they were subsequently reported by heart wire .
Shah said the study's follow-up-visit schedule was designed to mimic how comparable patients would be followed in clinical practice and reflected the standard of care at the three participating centers, which were Duke University (Durham, NC), Brigham and Women's Hospital (Boston, MA), and Columbia University (New York, NY). About half the patients had been hospitalized for heart failure at least twice in the previous year, and many had multiple comorbidities, including hypertension, diabetes, and renal insufficiency.
Over 120 days of follow-up, caregivers at the clinics initiated or fielded 581 patient phone calls that lasted a total of about 113 hours. That compares with 467 clinical visits that lasted 188 hours in all. The telephone calls accounted for 37.6% of time spent by caregivers--heart-failure cardiologists, nurse practitioners, and nurses--with the patients on management issues.
Shah pointed out some of the advantages of carrying out so much of the patient-education component of the disease management program by telephone; in this study, 53% of it was on the phone. "That's when the patients are learning, not during the clinic visit, when they are overwhelmed by everything that's going on."
Explicit reimbursement for such phone time by the Center for Medicare and Medicaid Services and other third-party payers would make it easier for institutions to set up the programs and hire nurse specialists to handle the calls, Shah observed. "A lot of heart-failure programs are living on a tight budget partly because of the time spent on doing things like this, that aren't reimbursed."
The STARBRITE group calculated, based on estimated national hourly rates of $25.79 for a registered nurse's time, or $36.80 to employ an advanced practice nurse, that the over-the-phone care cost the programs about $2920 or $4166, respectively.
"That's not really that much compared with a heart-failure admission," Shah said. "If you don't have someone doing this, a patient could end up back in the hospital with an admission that could easily cost $7000 or $8000."
Shah MR, O'Connor CM, Nohria A, et al. Telephone heart failure disease management: getting something for nothing. J Cardiac Failure 2007;13(Suppl 2):S172. Abstract 338.
Heartwire from Medscape © 2007 Medscape
Cite this: Steve Stiles . Reimbursement: Time to Play Catch-Up With HF Disease Management Programs - Medscape - Sep 19, 2007.