We’ve known for years that good transitional care programs—services aimed at helping patients make the move from a hospital or skilled nursing facility (SNF) back home, or even from a hospital to a SNF, can improve the health of older adults and save money.

But a new study finds that even through Medicare recently began paying physicians extra for providing such care for older adults with complex medical conditions, doctors rarely provide the service. When they do, their patients are likely to live longer yet cost Medicare less money. But they don’t.

Most successful transitional care programs have been led by nurses who make home visits and sometimes follow-up telephone calls. These programs help patients with the often-complex task of managing their medications, reduce the chance of infections or other post-discharge issues, and even assist with follow-up doctor visits. These services are especially important for older adults with complex medical conditions and often-limited support from family caregivers. And they are especially valuable because hospitals, encouraged by Medicare’s payment rules, discharge patients more quickly.

A doctor-based program

Following the success of these nurse-based programs, developed by innovators such as Mary Naylor at the University of Pennsylvania and Eric Coleman at the University of Colorado, Medicare created a physician-based transitional care management (TCM) payment code. Under this program, patients get an enhanced transitional care office visit right after their discharge from a hospital or SNF. They may also get follow-up phone calls or emails, some training for themselves or their caregivers, and other support.  Participating doctors get a modest additional fee (an average of about $40 on top of their regular office visit payment) for providing these services.

The new study by Andrew Bindman and Donald Cox, published in the journal JAMA Internal Medicine, finds that the program is beneficial, at least based on the early evidence.  Patients receiving the services were less likely to die in the month after getting the services and Medicare costs were about 10 percent lower compared to similar patients not in the program. They found that it worked best when participating docs saw patients within two days of discharge. But even an office visit within 14 days resulted in fewer deaths compared to similar patients who did not participate in the program.

Few docs are participating

Now the bad news: Almost no doctors are participating in the program. In its first year—2013—only 3 percent of Medicare patients discharged from inpatient care got physician-based TCM services. By 2015, doctors billed for the service following just 7 percent of discharges. And participation was highly concentrated among a relatively few docs. About 10 percent of participating medical practices accounted for more than two-thirds of billed TCM services.

Most participating physicians are primary care docs and an outsized number practice in Accountable Care Organizations (ACOs), practices that are rewarded by Medicare if they reduce costs and improve health outcomes of patients.

If the program pays more and reduces mortality (at least in the very short term), why don’t more doctors participate?

Why not?

Bondman and Cox didn’t study this, but they have some thoughts:

Physician practices may not have the systems required to meet Medicare’s complex, time-sensitive rules. A participating doc must contact a patient within two days of discharge, see some patients within 7 days, and others within 14 days, and not bill for the service until 30 days after discharge.

One problem: Because physicians rarely see their patients in hospitals these days, they may not even know that someone in their care was discharged until after the two day period has elapsed. Electronic medical records are supposed to solve this problem but, unfortunately, they often don’t.

The authors also suggest that physicians also may be avoiding the program because the extra $40 office payment may not be sufficient.

One other thought (mine, not theirs): Much of this kind of transitional care does not need to be provided by an MD, and perhaps should not be. Nurses, nurse practitioners, physician assistants, and in some cases even social workers can probably do at least as good a job as docs, at less cost. These professionals may be based in a physician practice but the docs themselves would not be doing the transitional care work.

We know that transitional care is an important part of successful discharges from hospitals and nursing homes. And physician-based programs such as TCM may have an important role to play. But only if doctors are willing to participate.