Health Tech Innovation-What will Stick?

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New Value in Underappreciated Activities

Healthcare professionals will agree with me here. Some of the most crucial work we do with patients has no billable code, and therefore, no value, in American healthcare reimbursement. This has had major ripple effects you may never have thought about, even if you feel them.

We are starting to see some new billing codes addressing this problem, the unintentional consequence of fee-for-service and who has determined the monetary worth of which services. Many of these newly-billable services are outside the skillsets of the providers whose influence is so important in shaping patient behavior (and behavior change is at the crux of what makes a VBC program successful). (On the established value of medical care: If you aren’t familiar with The Relative Value Scale Update Committee (RUC), here’s a place to start if you are interested.)

Let’s start with examples:

Explaining, demonstrating, coaching, and motivating a caregiver to mobilize a fragile, weak patient safety and effectively. This often has to be done repeatedly over time. Supporting the caregiver so they are most likely to be successful, know how to act and remain calm in an emergency, know their options when they need a break (aka caregiver training).

Teaching, coaching, motivating, explaining to a diabetic how, why, when to manage their blood sugar, eat well, act quickly and effectively in emergencies, recognizing emergencies, addressing behavioral and social determinant of health barriers (aka diabetic education).

Communicating effectively with patients about their serious illnesses. Discussing self-management, effectiveness of treatment options, risks and benefits, the basis for recommendations for or against a treatment. Discussing the illness’ trajectory and what to expect, what will change over time, how to prepare, how to address exacerbations effectively, how to reach the care team. Preparing them and their loved ones for choices that will come, for decisions to consider, and for how you can and will support them. Introducing them to the MOLST/POLST concept (I wrote about that here) and re-introducing and addressing it at any changes in condition and at regularly during communication. Coordinating communication and handing this off, as appropriate, with a specialist (aka advanced care planning).

In these three examples, we do have billing codes and/or billable programs that can address these activities. Are they valued appropriately? Are they being used systematically and effectively?

Generally, no.

Why?

Because while yes, there is the incentive of reimbursement available for the work, there is no incentive to improve the outcomes when that work is done well.

Yes, that incentive is important.

Where creating sustained patient behavior change is the actual care, and not medication, injection, surgery, (or the small number of output types typically provided by a physician or APP because of the structure of the reimbursement), the quality and level of success of the outcome long-term is dependent on communication, connection, time (and more time), perseverance, patience (and more patience), and the level of skill of the healthcare professional.

The true financial opportunity available is the annual and long-term reduction in spend and improved outcomes, which are not reimbursed or recognized in how we pay for or value healthcare in fee-for-service. But they are key ingredients in achieving shared savings and “back-end payment” in accountable care organization and other VBC structures.

More details on the above services:

Caregiver training codes are new in Medicare and in alternative payment model payments for 2024. They are being offered in FFS and as a component of comprehensive prospective payment mechanisms.

Some are billed by PTs/OTs/STs, others are used incident-to a physician or advance practice provider, or by the providers themselves. Rehabilitation professionals have been doing this work without billing codes since the profession was started. Many patients won’t reach or maintain their goals unless a well-trained caregiver assists and supports them well.

Diabetes Self-Management Training (DSMT) programs go through an accreditation process every 4 years. Patients can receive up to 10 hours (mostly in group sessions, with exceptions) the first year, and two hours annually. A wide variety of providers may provide the service, including registered dieticians, licensed clinical social workers, physicians, and APPs.

Primary care and/or endocrinologist buy-in and interest in developing and coordinating a referral program, tracking hours, billing, communicating about the program options with patients, coordinating between providers and clinicians, are all barriers to adoption and to proactively engaging with and motivating patients with diabetes to participate and remain committed to the program.

Advanced Care Planning largely wasn’t considered the job of physicians until recently. Available time-based billing codes have begun to change that, but this work is often not within the skillset or comfort of the providers who can bill for it. Adding this as a quality measure and as part of alternative payment models are attempts to incentivize widespread adoption.

There’s a long way to go and a lot of opportunity. Done well, done as often as needed, done proactively, done as standard practice, and patients and their loved ones with serious illness would have more control over their health and healthcare. Low value spending at the end of life and a poor end of life experiences would be less common, and fewer patients would spend their last days with uncontrolled symptoms and pass away in acute care hospitals and inpatient post-acute settings.

Why are Health Tech Innovators Flocking to These Spaces Now?

As fee-for-service services, the above examples are seeing some adoption.

But the opportunity to impact long-term health outcomes with these service types and the motivation by providers to offer and integrate them into standardized practice is the result of compounding investment opportunities.

What are “compounding investment opportunities?” in healthcare?

Just like the exponential growth potential of dollars invested and time to appreciate the compounding effect, the hard work of value-based interventions that involve behavior change yield their greatest results over time.

It’s one thing to develop a program and establish efficient operations so patients can be identified as candidates for a program or a service, participate, and receive the benefits. Some patients will naturally engage with the service because of personality, some will be told about it once and not follow-through. Others will participate with encouragement and support.

There is a business case for many of the programs even in fee-for-service, and the billing codes allow providers to build “muscle memory” in offering and operationalizing new support options for their patients. It’s a great place for a provider to start their journey into value-based care services.

It’s also an entry point for many vendors to offer tools, clinician support, compliance, and a host of new solutions to facilitate adoption.

In fee-for-service, the benefits are increased revenue, and the return on investment is highest when the vast majority of the work involved is offloaded to a vendor. They essentially share the profits with the billing provider.

But fee-for-service is not the only reason many new companies are developing and selling their products and services.

Health tech innovators following policy trends saw the value-based care opportunities as inevitable

Enter Providers Taking Financial Risk for a Population of Patients through Alternative Payment Models

Scenario: 

I’m a provider in a primary care practice who has adopted some chronic care management service offerings, telehealth, and annual wellness visit services. I am enjoying the patient satisfaction and additional reimbursement. I’m also learning about newly-available codes that will allow me to bill for other work my teams are doing or want to do.

I’m considering taking advantage of the Advance Investment Payments (AIP) option available in the Medicare Shared Savings Program (MSSP) to participate in the MSSP for the first time next year. As I learn more, I realize the more I can do as a practice to prevent my patients from needing acute care and reducing annual (and lifetime) inpatient, acute healthcare services, the more I can earn as a reward from CMS because my patients’ annual total cost of care is less than it was historically and that was expected based on their medical complexity.

What we have seen is that when primary care practices transition towards advanced primary care practices and take on more accountability for their patients’ health outcomes, the more that downstream spend is reduced and patients are healthier (and their engagement in their health is better).

While there are many levers to help providers and their patients be successful, and for providers to shift spending out of inpatient care and into primary care, the ones I point out here are related to historically undervalued services like the ones mentioned above.

Other examples are part of the Medicare Preventive Services list:

Then there are the health equity services in the 2024 Physician Fee Schedule Final Rule. Here is the MLN.

And don’t forget the chronic care management services. Here is the MLN.

So if my practice is part of an ACO and I provide and bill fee-for-service for appropriate, high-value services that, if done in a meaningful, patient-centered way, should reduce total cost of care and shift healthcare dollars to my outpatient practice setting, wouldn’t I be more likely to more heavily invest in and adopt innovative health tech solutions?

ACO Success Levers:

In this blog post, the analytics company Care Journey shared five simple bullets worth repeating:

Said another way, successful ACOs leverage both data and analytics and the services outside of transactional, in-office, fee-for-service care. They can’t do this with the tools they use today.

That’s the reason that CMS re-imagined the ACO Investment Model (AIM) program from CMMI to create the AIP. Provide interest-free, no-risk, up-front shared savings to practices entering the MSSP so they can properly invest in tools that lead to care transformation.

Which Products and Services Will Have Staying Power?

If you like to think about health tech solutions’ viability in the long-term, keep reading. I would bet on solutions that:

• Extract new value out of evidence-based interventions, like the earlier examples (new codes, new programs, etc.)

• Facilitate patient engagement, reducing burden on clinicians and encouraging patient participation

• Offer convenient, reliable, in-home care (remotely and in-person, for urgent, emergent, and short-term and long-term needs)

• Help providers make the best decisions at the point of care

• Simplify communication between providers and clinicians and teams to patients receive the right care at the right time by the right provider

• Optimize and simplify inpatient to outpatient transitions of care

• Facilitate primary care to specialist remote consultations and expand “primary specialty care” proficiency at the advanced primary care level

• Result in reduced medically futile care in the last year of life

• Help patients and caregivers identify the best courses of treatment based on what matters to them

Additional Reading: