As your practice makes adjustments for new care and reimbursement models, don’t forget there’s value in helping patients understand the value-based care definition.
It has taken time, and continues to take time, for physicians to get used to Medicare’s continued shift from fee-for-service to value-based care, but it's also an adjustment for patients to understand the definition of value-based care. Just as you are used to traditional, face-to-face office visits, your patients are comfortable with a care approach that involves coming in for an appointment, speaking with a doctor in the exam room, paying at the counter for service, and then leaving with a planned return appointment for the future.
Between-Visit Care, Coordinated Care, Connected Care
Now, Medicare patients are being asked to understand why their doctor is providing them with non-face-to-face services. They’re having unfamiliar terms thrown at them like between-visit care, coordinated care, and connected care, particularly as they relate to Medicare’s Chronic Care Management (CCM) program.
And it doesn’t help that both physicians and patients alike get tripped up not only on the exact value-based care definition, but also on the phrase "Chronic Care Management.” Many patients hear the word “chronic” and think it doesn’t apply to them. Physicians hear the phrase “care management” and generally think of a different type of service than the care coordination that is CCM.
But I’m “Not Sick”
Still, it’s important for Medicare patients to understand the value-based care definition and that they have both traditional and newer services available to them that can dramatically improve their health and lifestyle, while also saving them time and money. It’s just not easy to see the value in programs you simply don’t understand.
Couple that with an aging patient population that frequently identifies itself as "not sick” - even when as many as 3 out of 4 persons age 65 and older have multiple chronic conditions and 7 out of 10 deaths each year in the U.S. are from chronic diseases - and you can see why we need thought leaders who are spreading the word to peers and helping patients understand value-based care.
Patient and Peer Healthcare Education
Clearly, some top-down internal education is in order, as well as patient education. So, as you adjust to the requirements of value-based programs yourself, don't forget to help your staff and your patients understand the value-based care definition and what these changes in the healthcare industry mean for them.
To assist you in that effort, we encourage you to share information about the following Medicare programs and services with your staff so they, and you, can share insights with your patients when appropriate.
The “Welcome to Medicare” Preventive Visit
This one-time, introductory visit is provided to a new Medicare patient only within the first 12 months that they have Medicare Part B. Included in the visit is a review of the patient’s medical and social history related to their health, as well as education and counseling about these preventive services:
- Certain screenings, shots, and referrals for other care, if needed
- Height, weight, and blood pressure measurements
- A calculation of the patient’s body mass index (BMI)
- A simple vision test
- A review of the patient’s potential risk for depression and their level of safety
- An offer to talk with them about creating advance directives
- A written plan that lets them know which screenings, shots, and other preventive services they need
The “Welcome to Medicare” visit is not mandatory for the patient to be covered for yearly “wellness” visits.
Annual Wellness Visits
The importance of having an annual wellness visit (AWV) cannot be understated. The AWV is designed to proactively collect health, social, and functional information and to create personalized prevention plans for patients and their care teams. The AWV identifies preventive care opportunities that can improve health outcomes.
An AWV is classified as a preventive wellness visit, as opposed to a routine physical checkup. This distinction is vital to note because Medicare does not cover, reimburse, or provide coverage for regular, routine physicals, regardless of their frequency. It does, however, provide coverage for an AWV to patients who have had Part B for longer than 12 months, and it allows for this type of visit once every 12 months (11 full months must have passed since the patient’s last AWV).
The AWV includes a Health Risk Assessment (HRA) and a 30-minute screening visit. During the screening visit, the patient’s HRA is reviewed, vitals are taken, any cognitive impairment is determined, potential risk factors are reviewed, a medical/family history is established, a functional capacity evaluation and a safety analysis are performed, and a depression and anxiety screening is completed.
Based on the AWV, three health-related documents are developed for the patient:
- A Risk Factor Analysis - This outlines any chronic issues that the patient is facing. In addition, this analysis assigns a point value to these concerns, and assists with developing a treatment plan.
- 5 to 10 Year Plan - A preventive care plan, screening schedule, or screening checklist, this written plan shows the patient's plan of care over the next five to ten years. It must be updated annually after each AWV. It takes into account the current health status, the patient's screening history, and any steps that Medicare might recommend and reimburse for.
- Personal Health Advisement - The patient is provided with this document to aid them in their wellness efforts. The advisement will include referrals, education materials, and advice on preventive counseling services. One of the primary focuses of the Personal Health Advisement is to promote autonomy and self-management in different areas like getting the proper amount of physical activity, attaining and keeping a healthy weight, and tobacco cessation.
Transitional Care Management
According to the American Academy of Family Physicians, Transitional Care Management (TCM) “includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domicile, rest home, or assisted living).”
The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days. TCM is designed to prevent readmission to a hospital setting, and thus reduce costs in the process.
Chronic Care Management
Medicare’s Chronic Care Management (CCM) program provides non-face-to-face care coordination services to eligible Medicare beneficiaries with two or more chronic conditions. What began in January 2015 with a single code has since been expanded in 2017 to include additional reimbursements, new complex CCM codes, and options for easier enrollment.
The program takes a proactive approach to helping patients achieve optimum health, while putting physicians and practices in the best possible position to receive reimbursement for their care coordination efforts.
Because it recognizes the importance of taking care of the patient all of the time, not just at the point of care, CCM services involve between-visit care that focuses on characteristics of advanced primary care such as:
- A continuous relationship with a designated member of the care team
- Patient support for chronic diseases to achieve health goals
- 24/7 patient access to care and health information
- Receipt of preventive care
- Patient and caregiver engagement
- Timely sharing and use of health information
Practice staff can learn more about CCM in this article, which includes information about how the program was expanded in 2017. Physicians will find this CCM White Paper a more comprehensive review of the program. And patients can learn more about the value of CCM and its care coordination services here.
Advance Care Planning
Medicare began reimbursing physicians for helping patients with Advance Care Planning (ACP) in January 2016. ACP is about making decisions now about the care an individual wants to receive in the future if they are faced with a medical crisis, medical emergency, or end-of-life decision and are unable to speak for themselves.
We’re Here to Help
CareSync offers care coordination services that support the Welcome to Medicare Visit, Annual Wellness Visits, Transitional Care Management, and Chronic Care Management. Connect with us to learn more! Call 800-501-2984 or email [email protected].