Susan Harkema

Advance Care Planning (ACP) is a highly impactful service to add to a provider’s practice. However, confusion around who can deliver and bill these services keeps healthcare organizations from fully embracing and adopting the offering. Let’s dispel some myths and clarify Medicare’s rules and requirements for ACP.

Since Medicare introduced care management programs in 2015, coverage has evolved to provide expanded opportunities for Rural Health Clinics and Federally Qualified Health Centers. Historically, however, new care management programs have been launched without initially including RHCs and FQHCs or with significant restrictions. There’s also a lack of clarity around what services RHCs and FQHCs can now bill under HCPCS code G0511 for General Care Management. In this article, we’ll highlight the programs that are covered, and offer recommendations for capturing maximum value.

What does it take to create an effective and profitable Remote Patient Monitoring program? Creating the best Remote Patient Monitoring use cases considers four factors: - The provider setting - Which medical conditions need monitoring - The technical capabilities of the patient population - The type of RPM device required In addition to these four components, each organization must consider how it will manage the program and its data. This is where ThoroughCare plays a critical role.

Since 2016, Medicare has reimbursed physicians for Advance Care Planning (ACP) counseling. Yet, despite studies indicating that most patients would rather die at home than in a hospital or nursing home, more than 25% do not die in their location of choice. While physicians may see the value of offering ACP, slow adoption stems from five reasons... ThoroughCare, supported by our integration with Honor My Decisions, provides a platform that addresses each of these five areas.

Several factors, including supply chain costs and competitive pressures, make it harder for independent pharmacies to realize profits and growth. From 2016-2022, the average independent pharmacy gross profit margin was 20.8% to 21.1%. The good news is that the pharmacist's role has been expanding since the COVID-19 pandemic, when pharmacists administered 45% of all vaccines. In fact, pharmacist-led interventions averted millions of COVID-19 deaths and hospitalizations. It’s estimated that healthcare saved over $450 billion because pharmacies relieved significant strain.

Increased economic pressures squeeze health plans, and providers seek relief from burnout and revenue loss while wanting to improve outcomes. Both parties are looking for ways to achieve cost reductions, enhance quality, and better the healthcare experience. In a previous article, we examined how payor-enabled, provider-delivered Chronic Care Management is expanding. We presented McKinsey’s research on four strategies to maximize ROI. Here, we will examine how care management programs support greater collaboration between payor and provider organizations toward shared imperatives.

Medicare permits healthcare organizations to subcontract care management services. This creates opportunities for care management service providers, who typically administer such programs on behalf of physicians or specialist groups. For care management service providers to adequately support their clients, they require an integrated digital platform to streamline care delivery. This allows service providers to do two things – scale their businesses and provide excellent service to each care site.

Advance Care Planning (ACP) adoption has been slow because clinicians don’t have ample time or are uncomfortable with the topic; patients tend to associate ACP with end-of-life. Today, however, ACP has evolved into a reimbursable priority that benefits adults of any age, as well as their families and providers. Certainly, the COVID-19 pandemic demonstrated the value of preparation when patients unexpectedly can’t speak for themselves. Considering that studies show that up to 75% of patients will need someone to make medical decisions for them in the future, now may be the right time to integrate ACP into your standards of care.

ThoroughCare offers more than a software platform for care delivery. User organizations also receive access to unique clinical support services that enable successful care management programs. This includes tailored training and a comprehensive onboarding process to help launch and scale care coordination services. While working with ThoroughCare, clients can leverage our 120-Day Playbook, a complete guide to starting and growing a new care management program. This resource provides step-by-step support for all the necessary elements key to success.

Physicians and clinical teams face a catch-22. They can’t gain patient participation and adherence without increasing health and disease education. Yet, they don’t have the time to engage patients deeply. But what if clinical teams used a focused approach supported by trusted, timely educational resources that maximized teachable moments? With ThoroughCare, physicians and care teams can access evidence-based, targeted, and timely educational content from Healthwise, all within their normal workflow.

Medicare’s care management programs, such as Principle Care Management (PCM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI), all rely on monthly patient engagement, typically conducted via phone or virtual care. Depending on the program and patient complexity, the monthly minimum billable time for care management activities could be 20, 30, or 40 minutes or more. The purpose of each program is threefold: to improve the patient’s health status, reduce emergency department and hospital utilization, and decrease overall healthcare costs. And monthly touchpoints are critical to making meaningful, long-term changes.

The Centers for Medicare & Medicaid Services (CMS) has released the Final Rule for its 2024 Medicare Physician Fee Schedule (PFS). According to a CMS fact sheet, this update “is one of several Final Rules that reflect a broader administration-wide strategy to create a more equitable health care system that results in better access to care, quality, affordability, and innovation.” While next year’s payment policies introduce notable changes—some good and others not-so-good— the 2024 Final Rule offers significant opportunities for organizations focusing on care coordination or offering care management programs, particularly for rural health clinics (RHCs) and federally qualified health centers (FQHCs).

There are numerous benefits to launching a care management program. These include measurable results for patients, such as improved healthcare access, efficiency, and health outcomes, as well as cost savings for Medicare, Medicare Advantage, and even commercial payors. But, there is also a substantial economic and value-added benefit to provider organizations, including those in primary and specialty care. Here, we’ll outline the financial and indirect economic benefits of establishing or scaling one of several care management programs. We’ll also provide a rubric for decision-making when designing a program and how best to quantify revenue potential.

Several factors are driving the adoption of team-based care coordination. Workforce shortages exacerbated by the pandemic, a growing population of adults living longer with chronic disease, and the shift toward value-based care models top the list. The Institute of Medicine (IOM) defines team-based care as being delivered by at least two healthcare providers. This includes coordinated collaboration with patients and their caregivers to accomplish shared goals within and across settings. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.” When combined, team-based care coordination can help providers and payors support streamlined, more efficient service delivery. This can lead to consistent patient engagement and help achieve better outcomes in health and cost.

Healthcare’s goal is to cure. However, Advance Care Planning (ACP), or end-of-life planning, can address the tension between care at all costs and ensuring an individual’s wishes are met when they can’t speak for themselves. Research shows that people would prefer certain treatments near the end of their lives over those they often receive. This disconnect can lead to burdensome and costly treatments that may increase suffering. While 25% of all Medicare spending occurs during patients’ last years, research shows that about 70% of adults prefer less aggressive treatments at the end of life. Observational studies have highlighted the many benefits of ACP. For instance, patients are less likely to die in the hospital, and they are more likely to receive care that is consistent with their preferences. More than 50% of Americans know the type of medical treatment they want to receive at their end of life, yet only about 22% have formally documented their wishes. Only 17% of patients say they’ve talked about it with their doctor.

Medicare’s care management programs, such as Principle Care Management (PCM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI), all rely on monthly patient engagement, typically conducted via phone or virtual care. Depending on the program and patient complexity, the monthly minimum billable time for care management activities could be 20, 30, or 40 minutes or more. The purpose of each program is threefold: to improve the patient’s health status, reduce emergency department and hospital utilization, and decrease overall healthcare costs. And monthly touchpoints are critical to making meaningful, long-term changes.

Medicare’s Annual Wellness Visit (AWV) can be instrumental in improving care quality for older adults. This yearly assessment captures information about a patient’s health and functioning to document disease and identify new or worsening risk factors. AWVs ask about lifestyle, social history, mental health and home environment. Documenting these details can help providers risk-stratify patient populations and develop comprehensive, personalized care plans that can close gaps. This can help clinicians better coordinate services, streamline collaborative decision-making and support value-based care delivery. AWVs have been shown to build stronger provider-patient relationships, secure additional revenue and contribute to cost savings.

Several factors are driving the adoption of team-based care coordination. Workforce shortages exacerbated by the pandemic, a growing population of adults living longer with chronic disease, and the shift toward value-based care models top the list.

Unaddressed health-related social needs (HRSN) can make achieving care plan goals difficult. Provider and payor organizations that assess, identify and work on HRSN can help remove barriers that would otherwise thwart clinical efforts. This can support more comprehensive patient care planning. Care plan requirements of value-based care contracts, Medicare’s Chronic Care Management program, or other care coordination services aim to improve health outcomes, control costs and engage patients.

Policy and value-based payment models promote the importance of managing transitions of care. Historically, hospitals were the primary focus of Medicare’s Hospital Readmissions Reduction Program (HRRP). However, consider that one in five Medicare beneficiaries is readmitted to the hospital within 30 days, and a high percentage of these readmissions are considered preventable. They cost the US healthcare system about $17 billion annually. Beyond cost, research has shown that 30-day readmissions are an independent risk factor for all-cause mortality that persists for at least two years. Despite hospitals lowering 30-day readmission rates for Medicare patients from 20% to 17.8%, care coordination between the acute setting and primary care providers is an essential next step in quality improvement.