This newsletter will deliver a monthly discussion of a tried and true, common practice in VBC, as well as introduce new ingredients from the salsa makers of the world, VBC innovations. Foundational topics in VBC will be discussed to help us all refine and perfect the reliable standard sauce of VBC operations. Plus, true innovations, new ingredients beyond the basics, will be showcased. 

These innovators have chosen to open their cabinets for us to see into their work, to display their special sauce, not keep it secret. You may or may not have the need or capability to apply these innovations, but at the very least, it should get the juices flowing for coming up with better ways to address the issues you’re facing. 

For this first newsletter, I’ll share an innovation I was heavily involved in creating, but future newsletters will feature inventive, cutting edge processes, workflows, and initiatives from experts in the field, like you! I guess this is akin to “I’ll show you mine and then you show me yours.” 

Silence and siloes stunt VBC growth and impede improved patient outcomes. Open platforms for conversation make us all better at our jobs – and improve the lives of our patients. Let’s talk sauce ….

Tried & True

In this inaugural edition of our newsletter, I would be remiss if I didn’t start the “tried and true” section with an article about a foundational piece of VBC success - the Medicare Annual Wellness Visits (AWV). An AWV can serve as a keystone in the transition from fee-for-service (FFS) to value-based care (VBC), and a well done AWV has a broad-based positive influence on a wide array of the work to be done in VBC. 

An AWV can be a revenue generator, paid at a higher rate than a typical office visit, generating more productivity points (RVUs*). This would seem counterproductive to a move to VBC where one wants to decrease medical costs. However, when trying to move a practice or a physician from a FFS model based on collections or productivity to a VBC model, the incentives in physician compensation need to be aligned with the work of VBC. Motivating this alignment using encounters that will later yield a big ROI for VBC, like AWV, eases that transition.

A Medicare Initial Annual Wellness Visit (G0402) carries a weight of 4.89 RVUs, and the Subsequent Annual Wellness Visits (G0439) are worth 3.26 RVUs. Compare this to the typical office visits 99213 and 99214 which carry RVU rates of 2.05 and 3.01, respectively. Encouraging docs to switch mindset to doing an AWV versus and “annual checkup” positively influences their FFS compensation, if based on collections or production. 

Additionally, AWV work doesn’t need to all fall into the lap of the physician. Most of the work can be completed by other medical professionals. This frees up the doc to spend more time with other patients.

Though we’ll spend some time on Advanced Care Planning (ACP) in another newsletter edition, it needs to be mentioned now in this context of changing physician habits while transitioning them from production-based to outcomes-based compensation. ACP can be done as a component of an AWV. For subsequent AWVs (G0439), the ACP can be billed in addition to the AWV, accounting for an additional 2.23 RVUs. The patient copay is waived on the ACP when it’s done in conjunction with an AWV, so it’s no increased out-of-pocket expense for patients.

But we’re just increasing the medical spend with these moves, right? Up front, yes, but the value created by helping build patient attribution to a physician, through addressing proper coding of a patient’s burden of illness, and because an appropriately completed AWVs (and ACPs – another time) saves money on the back end through improved outcomes all more than make up for the increased front-end expense.

*In reality, RVU stands for Relative Value Unit, but it has little to do with value. It’s a relative cost indicator designed by a Harvard Business Professor and embraced by CMS and the AMA. It’s commonly used for measuring production of physicians and practices, much to the chagrin of PCPs.

This is why AWVs are truly the Swiss Army Knife of VBC. So many useful tools all in one convenient package!

• Attribution

• Burden of Illness (Risk Adjustment) Coding

• HEDIS Measures of prevention and screening

• Medication Reconciliation

• Chronic condition and social risk management programs

• Relationship

Two important drivers of gross revenue in VBC are attribution and risk adjustment coding (burden of illness coding). Attribution is how patients are assigned to a specific physician, and risk adjustment coding documents a patient’s burden of illness, an important factor in determining the baseline, or benchmark of expected medical expenses. 

Basically, attribution is determined by which physician is involved in the plurality of care – has had the most billed touches with a patient. An important distinction is that an AWV will often be given more weight in the equation than a usual office visit (depending on the payer). Doing the AWV will help get a patient on your attribution list. It is only when a patient (member) is attributed to a physician that the physician can get credit for the work done in HEDIS measures, cost and use metrics, and shared savings (or the penalty for work not done).

Medicare and other payers adjust their premiums and expected expenses based upon the burden of illness documented in the population they’re covering. The higher the burden of illness (the “sicker” the patient) the higher the expected spend for their care. This is based on Hierarchical Condition Codes (HCCs) that are created and captured when a patient’s illnesses and conditions are documented in the medical and claims records. 

Accuracy and completeness of burden of illness documentation is essential in calculating a populations’ expected cost of care for the next year. For Medicare, this determines what CMS is either going to budget for medical expenses or pay to a Medicare Advantage plan in monthly premium. That monthly premium or estimate of spend is the benchmark that a practice or organization will have as a goal in shared saving or an expense risk contract.  

An AWV is the perfect opportunity to capture and recapture the accurate and specific coding of a patient’s conditions. Without an intentional effort at appropriately documenting a patient’s conditions and putting them on a claim, this process will often fall through the cracks.

HEDIS Measures dealing with prevention and screening can be addressed during an AWV. It’s a perfect time to ensure immunizations are up to date, preventing acute illness and complications of chronic diseases. Health screenings that a patient is due for can be ordered during an AWV.

Early detection of colorectal cancer and breast cancer greatly improves patient outcomes at a significantly lower cost than treating these conditions in more advanced stages. Checking patients with diabetes for kidney or retinal complications of their disease can be initiated in an AWV. In addition to being able to check the boxes for “HEDIS Quality” measures often tied to VBC revenue, patient care is improved.

Medication reconciliation is one of the most basic, most under-used, most important tasks in modern healthcare (besides handwashing). Patients and physicians need to agree on all the medicines a person is taking, reconciling them with their conditions and with other medicines, looking for potential interactions. Frequent checking of the med list can avoid confusion, poor control of chronic conditions, and possible adverse reactions.

Patients are seen by many different providers and get prescriptions from most of them. Sometimes patients confuse brand names on a bottle with generic names of the same drug, taking both to try to ensure adherence to their doctors’ orders. Other times a medicine is stopped by one physician without the rest of the docs knowing a potentially essential med for disease management has been stopped. Or, the med was stopped due to adverse conditions, but the next doctor restarts it for the patient, because it’s on “their list.” 

A component of an AWV is medication reconciliation. When done properly, adverse reactions or disease decompensation can be avoided, decreasing the need for ED visits and admissions, i.e., decreasing costs. 

While in the office for an AWV, a patient’s current and new chronic conditions can be discussed. Questions can be asked to discern their need for extra help and support with these conditions. Likewise, social risks can be identified that might negatively impact their health and well-being. 

A successful VBC program will have designed programs to support patients clinically and socially to improve outcomes and decrease costs. The AWV serves as a great opportunity to assess progress with these programs or identify patients in need of the programs and introduce the patients to them. 

Relationship is a factor in healthcare that is difficult to quantify but with known benefits in patient care and outcomes. Relationship improves engagement and adherence to medical advice. Relationship opens the doors to conversations about social risks and barriers to care. Relationship improves the chances that a patient will first reach out to the physician’s office with medical questions and issues rather than immediately trotting off to the Emergency Department. 

A good way to build a relationship is to have presence with each other. AWVs foster relationship not only through more time spent together with the PCP Care Team but spending that time exploring ways with the patient to improve their health and well-being – helping them feel cared for. 

So, back to the question of why would we want to increase the cost of an office visit by doing an AWV? As we encourage FFS docs to intentionally do AWVs from a productivity perspective, we eventually see a significant ROI through improved outcomes and decreased costs. The AWV allows for impact in so many areas, offsetting the slight increase in cost. 

• Helping ensure attribution of patients

• Appropriate coding of burden of illness to set benchmark

• Prevention and screening, PLUS any bonuses paid for HEDIS measure completion

• Patient safety and appropriate disease management through medication reconciliation

• Identification of medical and social risks that would benefit from a guiding hand

• Fostering the Patient-PCP relationship

For this reason, practices need to focus on the timely completion of AWVs for their Medicare population. (Timing of when a patient can get an AWV varies between Traditional Medicare and Medicare Advantage plans – know the rules and who the patient has for a payer.) Dedicate resources to finding who needs an AWV scheduled. Consider flipping a scheduled visit to an AWV. Intentionally attend to the components of a valuable AWV, and get the whole team involved in the office, letting everyone work to the top of their license.

It seems so basic. Start paying attention to AWVs done right. It will smooth your transition to VBC and aid in the success of outcomes-based care.

Innovation doesn’t have to be a fancy, new idea, or a high-tech solution to a problem. Innovation comes from applying ingenuity, thinking anew about an issue. Finding an inventive path to reach a common goal. In fact, sometimes the best innovations are the simplest.

I’ve had the opportunity over the years to work with several health systems and physician groups in their journeys toward creating value in the delivery of healthcare. Many of these organizations have put inventive ideas, processes, and workflows into place to augment their foundational work, and I’d like to share one of those innovations with you.

A health system had used its food service vertical to build a meals-at-home program for patients recently discharged from the hospital after a bout of pneumonia, COPD, or heart failure. The plan was to feed the patients for 30 days to avoid a readmission to the hospital and the CMS penalties associated with readmission. The home-delivered meals proved to be a successful intervention, decreasing the incidence of readmission in the patients participating versus those that didn’t.

Unfortunately, since the service was not billable up front and the only hope of resource recoupment was through avoided CMS penalties, the health system put the program on mothballs.

Fast forward 3 years to when the health system stood up a Medicare ACO.

Since an ACO strives to create value through decreased medical expenses, and a good portion of medical expense is driven by admissions and readmissions for patients with chronic medical conditions, the leaders of the ACO looked for ways to positively impact their members’ care, and the expense. When word of this previous feeding program surfaced, the ACO leaders chose to take it to the next level.

Their plan was to find a very vulnerable cohort in their ACO population and not wait for an admission as a trigger to intervene. They chose a group of patients with all three diagnoses of COPD, Heart Failure, and Malnutrition, and they would proactively bring food to these folks in their homes. The cost of the delivered meals was $700 per patient per month. 

It’s no surprise that review of the data for the individuals in this group showed high Emergency Department (ED) and inpatient utilization, averaging one ED visit and about 0.8 inpatient admissions per month. Their annual medical cost was over 6 times that of the usual patient in the ACO. 

They identified 30 patients that met the inclusion parameters. Just under 20 accepted the program, with the other citing food choice and stranger avoidance as the primary reasons for declining.

After 6 months of delivering meals to the patients’ homes, the cohort showed almost an 80% decline in ED visits, and none of the patients had been admitted to the hospital. What had been a monthly cost of about $160,000 (one ED visit + 0.8 inpatient admission per patient per month), or $960,000 over 6 months, decreased to about $77,000 over the course of 6 months (meals + ED visits). The ROI was over 13 to 1, and more importantly, these people enjoyed better health and more time in their own homes.

Let’s break down the concepts of this innovative approach to supporting patients.

1. Identify high, impactable costs – Where are the costs you can change? Which patients are generating these costs. High utilizers are always a good place to start, especially when they have chronic medical conditions.
   

2. Stratify and define the risk cohort to be very specific at first – Find a manageable cohort size, especially when trying a new intervention or process. After proof of concept, it can be scaled out to include a broader population, as long as a positive ROI is maintained.
   

3. Know your baseline data – You can’t judge improvement if you don’t know where you started. You need a benchmark to measure against, plus this helps you define the best metrics to use based on their availability and perceived accuracy.
   

4. Commit resources to an intervention for a specific timeframe – There was no billable code or Medicare reimbursement for delivering food to these patients’ houses. The costs needed to be added up and assessed for a possible ROI. We anticipated an ROI of around 3-5 to 1 based on projected improvements calculated from previous readmission prevention data for this type of intervention. The plan was to fail fast within 4 months if no improvement was seen. With that planning, we committed to spending this money in an effort to improve overall costs.
   

5. Introduce one tactic to influence the cohort – The plan was to just add nutritious meals to the management of these patients’ care. We did not provide additional disease education or extra office visits. It’s not that these are good things, but it’s easier to assess the impact of an intervention when it’s isolated.
   

6. Account for unintended effects – After the fact, we determined there may have been a slight confounder to our findings. The meals were delivered once a week by a human. That human took the meals in the house, unloaded them into the freezer, reminded the patient how to heat the meals, and usually asked about their welfare. We could not quantify this human interaction effect, but it likely did have some benefit in addressing the social isolation often experienced by older folks with chronic medical conditions.
   

7. Measure the results – Aided by a baseline measurement, the same metrics were evaluated, showing a benefit in this case. Since the typical costs of inpatient admissions and ED visits are known quantities, cost justification became an easy exercise. 

Feed people healthy food to keep them healthy. That’s a pretty simple idea, yet the innovation of a process to deliver on that (literally) had huge benefits for the ACO, and more importantly, for the patients.