Blog Post

Easing into Population Health

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Committing to population health management (PHM) strategies has been a challenge for many healthcare organizations. Between the fear of financial losses from traditional fee-for-service (FFS) revenue streams and the sheer effort of deciding how best to initiate PHM activity, organizations have been slow to prepare for value-based care.

But with the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician organizations that continue to delay are likely to see reductions in Medicare Part B payments. Sitting on the sidelines of an environment that continues to shift toward value will make financial sustainability difficult.

The Good News

Of course, rushing headlong into the development of an advanced value-based payment model without first learning the basics of population health isn’t easy – nor is it advisable.

Fortunately, organizations that rely heavily on FFS still can ease into PHM without a major commitment to building program structure, bearing risk, or developing large-scale alternative payment models. CMS offers several payment models that organizations can use as a bridge to PHM in an FFS context.

Over the next several weeks, we’ll take a look at three programs that can enable organizations to continue billing FFS while laying a foundation for population health.

Transitional Care Management

Transitional care management (TCM) codes, introduced by CMS in 2013, allow providers to bill for helping patients transition from the inpatient setting to a community setting, such as home or assisted living. The PCP takes on the role of coordinator in a patient’s post-acute care, even for care delivered outside of the PCP’s office, as a means of ensuring appropriate follow-ups and helping to avoid unnecessary readmissions.

Building a Fee-for-Service Bridge to Population Health

To learn more about transitional care management and other programs that can serve as a foundation for value-based care, check out the cover story in the November 2016 issue of hfm.

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What it Entails

To be paid under the TCM code, a physician must:

  • Communicate with the patient or patient’s caregiver within two business days of inpatient discharge.
  • Engage in medical decision making of at least moderate complexity.
  • Conduct a face-to-face visit within 7 to 14 days of discharge.

Participating in TCM activities presents clear revenue opportunities for physicians. In 2013, CMS estimated that TCM services could generate a 2% to 4% increase in total collections for a PCP, and that two-thirds of discharged patients would be eligible for these TCM payments. At the same time, participating in TCM services can build providers’ experience with PHM quality and care management activities, which will prepare them to perform well under MACRA.

Below are some of the challenges PCPs often encounter when implementing TCM services, along with tactics to overcome them.

Challenges Tactics
Ensure the PCP is notified of eligible patients being discharged from inpatient facilities.
Use IT-enabled alerts to automatically notify PCPs when their patients are admitted to and discharged from an inpatient setting.
Establish an efficient work flow. Hire a care coordinator and build a work flow to guide TCM activities.
Appropriately document TCM services to comply with billing requirements. Work with the billing office to ensure documentation standards are built into the care coordinator’s work flow.