Medicare "fee-for-value" codes present an opportunity for providers still reimbursed under fee-for-service to fund investments in value-based care. However, these codes (e.g., TCM, CCM, ACP, BHI, AWV) are still heavily underutilized. A 2018 analysis found that despite demonstrating significant impacts on total cost of care and mortality, providers billed TCM in only 7% of eligible cases in 2015 (up from 3.1% in 2013). Similarly, a 2017 analysis found that only 4.5% of eligible providers billed CCM in the first 15 months of availability. And research published in JAMA Internal Medicine earlier this year found that use of ACP codes is less than 3%.
How to use fee-for-value to build a population health infrastructure
A few providers have figured out how to leverage fee-for-value codes effectively. For example, UNC Health has used these codes to build an infrastructure to support its ambitious risk growth targets—despite starting off with a relatively low number of attributed lives under risk. To do so, UNC staffs its medical homes with extended members of the care team who can provide reimbursable services: RNs, social workers, and registered dietitians.
To learn more about how to tailor your staffing investments based on the amount of risk you've taken on, check out our new primer, How to scale team-based primary care according to financial risk
However, a lot of red tape and paperwork comes with billing fee-for-value codes, and it can be frustrating for staff unaccustomed to being accountable for it. To ensure the extended care team members generate revenue without getting burned out by administrative tasks and having restricted patient pools, UNC set up guidelines for how staff should spend their time. It determined that 60% of nurse, SW, and dietitian time has to be dedicated to providing reimbursable fee-for-value services like TCM, ACP, etc., and the remaining 40% can be spent on unreimbursed care. With these guidelines, extended care team members offset 90% of their own cost. UNC absorbs the remaining 10% as an investment in population health.
Proposed rule is a win-win (especially for early movers)
But that 90/10 ratio may tip in UNC's favor following CMS CY2020 proposed outpatient payment rule. In the rule released at the end of July, the agency proposes a number of adjustments to TCM and CCM codes specifically designed to increase provider uptake. For instance, the agency recommends increasing the work RVUs associated with the codes (which essentially determine how much revenue they generate) and decreasing the administrative requirements around billing for them. Both of these moves are intended to address the biggest grievance we hear contributing to low provider uptake of fee-for-value codes overall: The payment organizations receive for the codes isn't worth the administrative burden they present.
For organizations like UNC, which have already figured out how to sustainably leverage fee-for-value codes, these changes could fully finance extended care teams and potentially provide additional revenue to finance the continued migration toward value. For other providers just getting started with care team investments in primary care, these changes may be just the incentive they need to make fee-for-service-friendly investments to prepare for population health.
How to scale team-based primary care
As health systems take on ever more risk—whether by choice or mandate—it's becoming clear that succeeding under value-based care requires a strong primary care network to help patients manage existing conditions and stay out of the hospital.
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