Leah Marcotte, MD Clinical Assistant Professor, Medicine Associate Medical Director, Population Health

Transitional Care Management Expands, Delivered Mostly In Primary Care Offices

MedicalResearch.com Interview with:

Leah Marcotte, MD Clinical Assistant Professor, Medicine Associate Medical Director, Population Health

Dr. Marcotte

Leah Marcotte, MD
Clinical Assistant Professor, Medicine
University of Washington

Joshua Liao, MD, MSc, FACP Assistant Professor, Department of Medicine Director, UW Medicine Value and Systems Science Lab Associate Medical Director, Contracting and Value-Based Care

Dr. Liao

Joshua M. Liao, MD, MSc, FACP
Assistant Professor, Department of Medicine
Director, UW Medicine Value and Systems Science Lab
Medical Director of Payment Strategy, UW Medicine
University of Washington


MedicalResearch.com: What is the background for this study?

Response: In the last 7 years, Medicare has implemented payment reforms to encourage primary care and other ambulatory providers for dedicated care coordination activities. One such reform, Transitional Care Management (TCM) billing codes, was introduced in 2013 and emphasized coordination during care transitions from hospital to home – a particularly vulnerable period in which patients may be at risk for adverse outcomes. TCM services include patient contact (e.g., phone call) within two business days of discharge, a visit (e.g., office or home-based) within 14 days of discharge with at least moderate complexity medical decision making, and medication reconciliation. TCM services may be delivered after inpatient hospitalization, observation stay, skilled nursing facility admission or acute rehab admission.

There have been few studies that have looked at early data in Transitional Care Management, and none that have described national use of and payment for these codes over an extended period of time. We analyzed a national Medicare dataset looking at 100% of submitted and paid TCM claims from 2013-2018. 

MedicalResearch.com: What are the main findings? 

Response: Transitional Care Management services have increased markedly from 298,536 services in 2013 to 1,291,827 services in 2018, representing $56,476,896 and $243,277,363 in payments, respectively. Eight percent of TCM services billed within the time period we evaluated were denied payment. Most services were delivered by primary care physicians (82%) and occurred in physician offices (87%). Over the course of the study period, home-based TCM services were infrequent, but had a small but significant increase from 2013 (1.6%) to 2018 (2.4%) (p< 0.001).

MedicalResearch.com: What should readers take away from your report? 

Response: Though Transitional Care Management use has expanded since its introduction, there is still opportunity for greater uptake. Approximately 5.8 million Medicare patients have a qualifying admission1 demonstrating that despite growth, TCM services are delivered to a minority of those eligible. There is also opportunity for specialist adoption of TCM services when managing patients with complex chronic conditions at discharge (e.g., an oncologist seeing a patient after admission for neutropenic fever or a cardiologist seeing a patient after admission for myocardial infarction).

Finally, the vast majority of Transitional Care Management services during the study period were delivered in office-based settings; there is potential to expand TCM services via home visits.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: There are major gaps in our understanding of Transitional Care Management use. Two stand out in particular: the need for rigorous quantitative evaluations of the impact of TCM on patient outcomes (clinical, quality, cost), and the need to qualitatively describe the strategies that providers use to implement and perform TCM activities, as well as facilitators and barriers to their use. The need for such insights is particularly critical to Medicare’s substantial and ongoing investment in TCM codes, and other care coordination codes like it.

No disclosures related to the publication in question. 


Marcotte LM, Reddy A, Zhou L, Miller SC, Hudelson C, Liao JM. Trends in Utilization of Transitional Care Management in the United States. JAMA Netw Open. 2020;3(1):e1919571. doi:10.1001/jamanetworkopen.2019.19571



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Last Updated on January 23, 2020 by Marie Benz MD FAAD