Mr. Wilson is playing basketball with some friends. He experiences some wheezing and some shortness of breath and has to stop playing. He is concerned that he may have a serious illness and wants a physician to examine him.
Under Current Payment Systems
Under Patient-Centered Payment
Mr. Wilson does not have a regular primary care physician, so he goes to the urgent care clinic. At the clinic, a nurse practitioner examines him and a radiology technician in the clinic x-rays his chest. He has no fever and there is no sign of pneumonia on the x-ray. The nurse practitioner tells him he may have asthma, and prescribes an inhaler for him to use. Mr. Wilson obtains the inhaler from the pharmacy, but he never uses it because the symptoms don’t recur.
Mr. Wilson enrolled a few months ago with a primary care practice to receive wellness care, so he contacts the practice and describes his symptoms. His physician “sees” him the same day through a telehealth visit and asks him a series of questions to better understand the circumstances surrounding the problem and to determine whether any emergency treatment is needed. The physician says that based on what she already knows about Mr. Wilson’s health history and what he tells her about his symptoms and the basketball game, she says she thinks it is unlikely that he has asthma and more likely that he was exercising more vigorously than normal and that he might also have a mild upper respiratory infection as a result of recent airline travel. She offers to see him in person later that day if he wants, but she says she also thinks it would be safe for him to wait for a day to see if his symptoms recur or worsen.
Based on what the physician told Mr. Wilson on the video visit, he decides not to come in to the primary care practice for an in-person visit. The nurse from the practice who has been working with him on diet and exercise contacts him the next day to see how he is doing and to have a more in-depth discussion with him about his weight and how much exercise he is getting. The nurse discusses the fact that Mr. Wilson has gained weight and talks about ways that he could get more exercise while he is traveling.
The nurse follows up again with Mr. Wilson a few days later. He has had no recurrence of the respiratory symptoms and says he feels fine. The nurse informs the physician, and they agree that no further action is needed.
The urgent care center bills Mr. Wilson’s insurance company for a visit, an x-ray, and the other tests the urgent care center performs. Mr. Jones and his insurance company pay their respective shares of the cost of the inhaler he gets but doesn’t use.
The primary care practice bills Mr. Wilson’s insurance company for an Acute Care Visit Fee under Patient-Centered Primary Care Payment. There is no additional charge or payment for the follow-up calls by the nurse, since the practice is billing Mr. Wilson’s health insurance plan for monthly Wellness Care Payments under Patient-Centered Primary Care Payment so that it can provide him with this kind of proactive care.