Nudging Medical Practice Change One Regulation at a Time

News & Analysis mission. “We don’t know how big a prob- lem it is,” said Susan P. Montgomery, DVM, MPH, epidemiology team lead in the CDC’s parasitic diseases branch. Of the 17 Texas blood donors with confirmed Chagas disease in her study, Garcia noted 6 were suspected to have acquired the infection close to home. However, blood donor screening likely detects only a small percentage of local or imported US cases, because those at high- est risk are underrepresented among donors, Garcia said. Furthermore, not all those with con- firmed Chagas had traditional risk factors, such as spending time in an endemic coun- try and staying in areas with substandard housing (Garcia MN et al. Am J Trop Med Hyg. 2015;92[2]:325-330). The researchers have found locally transmitted cases among people who live in rural areas or spend sub- stantial amounts of time outdoors. Garcia explained that local transmis- sion in the United States likely can be traced back to small mammals, such as wood rats, squirrels, possums, and skunks that act as reservoirs for T cruzi and serve as a source of constant blood meals for the triatomine bugs with which they tend to cohabitate. These animals then make their homes in sub- standard human housing and bring the in- sects with them, leading to human expo- sure to the parasite. In line with this mode of local transmis- sion, Garcia and her colleagues found a high prevalence of T cruzi infection among triatomine bugs in southwestern Texas. They reported at the ASTMH meeting that three-quarters of the 40 bugs collected from June 2013 to January 2014 were infected. The insects were predominantly collected near homes in rural areas, and an analysis of the infected insects found that half had re- cently fed on humans. Another potentially underappreciated source of local transmission is mother-to- child transmission, which can occur in 1% to 10% of pregnancies in infected women. Montgomery noted 1 confirmed case of T cruzi infection in an infant born in Virginia to a mother likely infected in Bolivia (MMWR Morb Mortal Wkly Rep. 2012;61[26]:477- 479). However, she and Bern estimated that at least 63 and as many as 315 congenital T cruzi infections occur each year in the United States (Bern C and Montgomery SP. Clin In- fect Dis. 2009;49:e52-e54). “The biggest thing we learned is that people …can get Chagas even if they haven’t left the country,” Garcia said. The JAMA Forum Nudging Medical Practice Change One Regulation at a Time Andrew B. Bindman, MD American Medical Association W ith the arrival of 2015, Medicare has implemented its long-de- bated chronic care manage- ment (CCM) payment policy (http://bit.ly /1xqSoVr). The policy represents a victory for the medical community, which has advo- cated for a means to receive payment for managing patient care that doesn’t involve a face-to-face visit, such as coordinating care with other practitioners, communicating with community-based service providers, and responding to emails from patients. Medicare anticipates that an invest- ment in CCM services could help reduce costs associated with emergency depart- ment visits, hospitalizations, and post- acute care in an institution. The new policy also has the potential to provide a signifi- cant new source of revenue for primary care practices that care for Medicare patients with multiple chronic conditions. Eligible practitioners who furnish a mini- mum of 20 minutes of service to create, monitor, or revise a care plan for a Medicare beneficiary with 2 or more chronic condi- tions are now able to bill $42 once per month for these services using a new Current Pro- cedural Terminology (CPT) payment code. jama.com Among other things, a practitioner using this new code for managing chronic conditions must make available a member of the prac- tice care team with access to the beneficia- ry’s electronic health record (EHR), includ- ing the care plan, 24 hours per day, 7 days per week. (The EHR system used also must meet certification criteria for the EHR incentive program established by the Office of the Na- tional Coordinator for Health Information Technology.) Billing is limited to a specific practitioner designated by a Medicare ben- eficiary with 2 or more chronic conditions to furnish these services. Approximately 20 million Medicare fee- for-service beneficiaries who have at least 2 chronic conditions make an office visit within a 1-year period (http://go.cms.gov/1yj7dgK). This care is provided by approximately 120 000 physicians who deliver primary care services within the Medicare program, which suggests that, on average, there are approximately 165 Medicare fee-for- service beneficiaries per primary care phy- sician (http://go.cms.gov/1yBtOUF). If an in- dividual physician furnished CCM services for all 12 months in a year to all 165 of these eli- gible Medicare beneficiaries, that would yield Andrew B. Bindman, MD more than $80 000 through the new pay- ment code. Of course, the experience of each phy- sician will vary, depending upon how many eligible Medicare beneficiaries are actually in the practice, the willingness of the benefi- ciary to designate the primary care physi- cian as the practitioner to furnish the service, and the number of months the physician ac- tually delivers the service throughout the (Reprinted) JAMA March 24/31, 2015 Volume 313, Number 12 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/933653/ by a UCSF LIBRARY User on 05/10/2017