The move toward value-based care involves “a reimagining of the traditional definition of health care delivery” with the aim of supporting better outcomes at lower costs, according to a report released by the AMA.
The report (PDF) notes that a decade of performance measures has shown that Medicare Accountable Care Organizations (ACOs) deliver quality care while saving Medicare money. But, despite these metrics, comprehensive adoption of value-based care (VBC) has been slow, with almost 90% of all U.S. health care physician payments in 2022 having at least a portion tied to a fee-for-service architecture.
“Sustainable adoption of value-based care is proceeding, though considerably more slowly than some of us would've predicted or liked, and the AMA is leading the national conversation on how it can be accelerated,” Tom Cassels, a managing director at Manatt Health, said at last year’s HLTH conference in Las Vegas.
Cassels served as moderator of a panel discussion sharing practical steps for facilitating digitally enabled value-based care. He added that this acceleration is being propelled, in part, by Current Procedural Terminology (CPT®) codes, the standard medical code set terminology for reporting medical services and procedures in the U.S.
The AMA is “playing a critical role in supporting the shift to value-based payment through leadership in areas ranging from physician practice adoption to stewardship of the CPT code set,” Cassels said.
Panelist Christopher Botts, the AMA’s senior manager of care delivery and payment, cited the AMA’s work with the health insurer trade group AHIP and the National Association of Accountable Care Organizations to advance sustainable value-based care adoption.
A highlight of that collaboration has been the publication of a playbook of best practices for value-based care payment arrangements (PDF). The playbook offers an in-depth guide to help overcome key challenges in such arrangements.
The playbook identifies “more than 90 best practices that are really focused on making participation within value-based care arrangements easier, and that will, ultimately, allow physicians and their care teams to focus on what they care about most—which is evidence-based, equitable, coordinated, whole-person care,” Botts said.
The payment best-practices playbook builds on prior work that was focused on improving data collection and sharing within these value-based care arrangements. The playbooks recognize that “time is a limited resource,” said Botts, who cited other common themes in these documents including:
- The importance of available, timely, relevant and actionable data.
- Alignment across different value-based care arrangements to alleviate physician practice burdens.
- Flexibility to support the needs of populations the practices serve.
- Transparency about payment methodologies.
Such transparency “is really critical to creating the trust that’s essential for succeeding under these specific arrangements,” Botts explained.
CPT codes evolve for what’s next
Panelist Zach Hochstetler, the AMA’s vice president of payment and coding, described the findings of the report, which includes market perspectives on how the CPT code set is the foundation of value-based care arrangements.
The report was drawn from a series of interviews with leaders at health care organizations that provide value-based care, along with those at health plans, integrated delivery systems, health technology organizations and others.
As a uniform language for medical services and procedures, the CPT code set enables stakeholders working in every sector of the health care ecosystem to understand and communicate the story of a patient’s care.
The findings of the report confirmed that CPT codes play a foundational role in value-based care around three pillars: patient attribution, budget and benchmark-setting, and identifying patients for clinical interventions.
Specifically, the report describes the CPT code set as a “critical enabler” of these three main areas:
- Population health and quality management, by driving identification of patients for targeted clinical intervention and supporting payer quality-improvement efforts.
- Cost management, by supporting spend benchmarking, risk adjustment and budgeting, enabling identification of high-cost events and high-cost patient cohorts, and enabling provider network management.
- Alternative payment model contracting, because CPT codes are foundational for patient attribution, the code set enables digitally enabled care bundles, and facilitates contracting between payers and companies offering digitally enabled care.
“There are a couple interesting things that surfaced from this research,” Hochstetler said of opportunities for the CPT code set to support where value-based care is going. These findings are informing how the CPT Editorial Panel is looking at evolving the code set to better meet the market’s needs.
The findings include:
- New people, such as community health care workers, are providing services and they are not always clearly identified in specific CPT codes.
- New delivery models are focused on bundling episodes of care.
“Innovative companies and physicians are looking for larger episodes-of-care bundles so that you don't have to understand all the reporting requirements for the different time-based codes,” Hochstetler said.
CPT codes for these bundles could be reported whether care was delivered in person, virtually or via text.
“Rather than have three separate codes for that, can that just be part of a continuum of care?” Hochstetler asked. “Then, typically these value-based care arrangements have the ability to appropriately pay for those services.”
He added that a strategic plan is being developed for review by the CPT Editorial Panel that will look for ways the code set can evolve to address that feedback. That work began last year when the CPT Editorial Panel established a dedicated value-based care work group. The members of the work group are responsible for evaluating how the CPT code set can more accurately reflect the clinical and operational realities of value-based models, which are increasingly team-based, digital and focused on outcomes.
Considerations are ongoing for how to thoughtfully modernize the CPT code set to further support value-based care. “As new models of VBC emerge—that involve greater use of multidisciplinary teams, digital tools and high-frequency patient interactions—the AMA and the CPT Editorial Panel remain committed to evolving the code set to ensure it responds to the needs of physicians, health professionals, health systems, policymakers and payers,” the report adds.
Addressing the digital divide
Cassels cited the “digital divide” as a barrier to value-based care and asked what can be done to enable wider use of digital health tools—especially in areas and populations with limited access.
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Panelist Narayana Murali, MD, system chief medical officer of medicine services at the Danville, Pennsylvania-based Geisinger integrated health system, noted that the digital divide is especially acute in rural areas.
Dr. Murali also described how Geisinger has partnered with Best Buy to send the retailer’s Geek Squad tech personnel to patients’ homes to install the digital equipment and teach patients how to use it.
“When we are looking for remote-monitoring or RPM [remote physiological monitoring] devices or any other technology—for example, diabetes, blood pressure and glucose monitors—we want those tools to be Wi-Fi-encompassing—with built in Wi-Fi connectivity and functionality to address the digital divide—so that the patient does not have to struggle in getting that particular piece for a seamless connection,” he said.
Geisinger is part of the AMA Health System Member Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
A former chair of the AMA Integrated Physician Practice Section, Dr. Murali served on the work groups that developed the playbooks for value-based care payment best practices, and he applauded the AMA’s role in helping accelerate adoption of these types of payment arrangements.
“It's important to also recognize what the AMA brings to the table as a convener,” Dr. Murali said.
“They're focused on the value-based care journey,” he added. “And they're focused on the playbooks that are required to have organizations recognize what are the basic elementary steps that you need to take.”
