Innovation and disruption
Value-Based Models Drive Need for Reimbursable Services for Team-Based Care
Eight years have passed since the Affordable Care Act perpetuated the idea of value over volume in the health care industry. The concept of the accountable care organization (ACO), designed to accrue shared savings while simultaneously focusing on population health, has continued to develop. Since that time, the number of public and private payer ACOs has exploded, with an estimated 10 percent of the U.S. population now receiving care from a provider contracted under an ACO. ACOs were the original Alternative Payment Model (APM) and provided a solid foundation for building out the risk-based pathway of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Value-based reimbursement in 2018
In 2018, MACRA continues to drive physicians toward value-based reimbursement models with the addition of six qualified Advanced APMs to the Quality Payment Program (QPP) for the current reporting year. Simultaneously, the Physician-Focused Payment Models Technical Advisory Committee (PTAC) has seen the submission of 21 proposals for physician focused payment models (PFPM) since April 2017. PTAC was created by MACRA to make comments and recommendations to the U.S. Secretary of the Department of Health and Human Services (HHS) on PFPM proposals submitted by individuals and stakeholder entities. The secretary is required by MACRA to respond to the recommendations of PTAC.
Most recently, the Centers for Medicare and Medicaid Services (CMS) announced a new voluntary, episode-based payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced). Based on the concept of aligning incentives across the continuum, BPCI Advanced will use 32 clinical episodes to reduce cost and improve quality. BPCI Advanced will be considered an Advanced APM of the QPP beginning in 2019.
Payment transformation is here
Regardless of the model, there are common attributes that must be considered during payment transition, keeping in mind that health care is local and maintaining a margin is still critical. These include cross-continuum stakeholder alignment, data access and integration, and care redesign. Care redesign will center on patient-focused care with a physician-directed team.
Core principals of care redesign
As care and payment models evolve, the need for a growing list of reimbursable services for team-based care is evident. The National Academy of Medicine defines team-based care as the strategic redistribution of work among members of a physician-led practice team. All members of the team play a role in patient care based on their licensure and share overall responsibility for outcomes. With the adoption of new value-based payment models, panel size commonly increases. Understanding risk of the patients within the panel is critical for optimizing team-based care and allocating resources to “top of license.” Care redesign can take many approaches, but is solidly built around these core principles:
- Build the culture-change team. Engage the right mix of clinical, administrative, and technology team members in order to manage the culture change. Consider patient representation.
- Build the care team and model. Design the care model around your patient population and consider including care managers, health coaches, behavior health specialists, care coordinators, physicians, advance practice practitioner, licensed clinical social workers, and others who share the passion for team-based care, continuous improvement, and communication. Defining clear, measureable roles and responsibilities is critical.
- Review your data and set improvement priorities. Improvement opportunities should be based on clinical, operational, business, and clinician satisfaction goals. Implement or modify clinical and financial metrics and continually monitor and adjust.
- Create team-based care workflows. This entails creating an ideal future state focused on team-based visits. Use LEAN or similar principles to ensure efficiency in current and future state processes.
Reimbursable services continue to grow
Reimbursement for team-based services is dependent on the payer and their respective billing and coding guidelines. The good news for existing and evolving team-based models is that CMS has acknowledged the shift in model design, and the list of reimbursable services continues to grow. While services like transitional care management and chronic care management have been billable for a few years, the complex requirements often hindered implementation.
In 2018, several services received permanent Current Procedural Terminology (CPT) codes, and services available via telehealth delivery were expanded. Though each model is unique based on composition and population served, below are services to consider in developing your organization’s model:
Expanded coverage in 2018 includes remote monitoring
Remote patient monitoring allows team-based models to receive patient-generated data, which could ultimately contribute to enhanced management, reduced cost, and improved outcomes. Additional billing criteria for remote patient monitoring includes:
- A minimum of 30 minutes must be spent in the collection and interpretation of data to report this service.
- Providers must obtain advance beneficiary consent for the service and document this consent in the patient’s medical record.
- For new patients or those not seen within one year before the provision of remote monitoring services, providers must initiate these services in a face-to-face visit, such as an annual wellness visit or physical.
- Providers can use code 99091 no more than once in a 30-day period, per patient.
- The code includes time spent accessing the data, reviewing or interpreting the data, and any necessary modifications to the care plan that result, including communication with the patient and the caregiver and any associated documentation.
- This code will not be subject to any of the restrictions on originating sites or technology that telehealth services are subject to by statute, allowing more flexibility for users of this technology.
Remote patient monitoring code
A physician or other qualified health care professional collects and interprets physiologic data. The data (e.g., blood pressure) is stored digitally and may be transmitted by the patient and/or the caregiver to the provider. The report should contain the time it took the provider to acquire the physiologic data, review and interpret the data, and modify any care plan due to the additional data acquisition. A minimum of 30 minutes must be spent in the collection and interpretation of data to report this service. Source: American Medical Association’s CPT 2018 Professional Codebook.
The Medicare telehealth benefit was expanded in 2018 to include care planning for chronic care management, health risk assessments, interactive complexity for psychiatric care, and psychotherapy for crisis.
How we can help
Payment transformation will require health care organizations to seek efficiencies and innovation in the way care is delivered in order to be successful into the future. CliftonLarsonAllen’s (CLA) health care professionals continuously research and understand transformational payment model development, performance, and improvement. Our approach connects regulatory changes to finance and operations positions, providing us with insights that few other organizations have. These insights, along with our commitment to understanding our clients, enable CLA to help our clients not only plan for change, but prepare for a promising future.