One common element that is sure to be carried over in the transition from a fee-for-service health system to one that supports value-based care arrangements will be the AMA Current Procedural Terminology (CPT®) code set, which is foundational to traditional payment models as well as new models that favor digitally enabled care bundles.
“It's really about redefining the traditional way that we've delivered care, and who delivers the care, where the care is delivered and, in most cases, how the care is paid for,” said Lori Prestesater, the AMA’s senior vice president for health solutions.
“We've been talking about value-based care for a very long time, with little progress,” Prestesater said.
But, she added during an episode of “AMA Update,” “we are now seeing a surge of people moving to value-based care and needing to be able to accommodate those new payment models.”
As the standard used to define medical procedures and services, the CPT code set has long been “associated with a traditional fee-for-service model of care,” Prestesater said. But she added that CPT has also become “a foundational building block as we … move to value-based care,” especially when it comes to conducting clinical research, establishing costs and supporting interoperability.
Prestesater also discussed the findings of a recent report (PDF) from the AMA and the consulting firm Manatt Health.
This research, coupled with AMA-developed educational content, best practices (PDF) and playbooks (PDF) for physicians, creates a suite of content that provides greater context to the nation’s understanding of value-based care models and helps physicians broadly adopt innovative value-based care (VBC) models.
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Three pillars of success
The AMA-Manatt report describes the objective of value-based care as “supporting better outcomes at lower costs” and notes that “CPT serves as the common language for VBC today and is a critical enabler of the three pillars of VBC success.”
Those three pillars are:
- Population health and quality management, by driving identification of patients for targeted clinical intervention and supporting payer quality-improvement efforts.
- Cost management, by supporting spend benchmarking, risk adjustment and budgeting, enabling identification of high-cost events and high-cost patient cohorts, and enabling provider network management.
- Alternative payment model contracting, because CPT codes are foundational for patient attribution, the code set enables digitally enabled care bundles and facilitates contracting between payers and companies offering digitally enabled care.
CPT facilitates patient attribution and helps describe preventive care, which can help patients avoid hospitalization and emergency department visits, Prestesater said.
“CPT really provides the foundation that helps to support that attribution, that then can establish the baseline for metrics,” she explained. “How are those patients going to be managed? How are those patients going to be measured? What can we do to improve the outcomes while we manage the cost?”
As the “foundational layer to identify a procedure or a service,” CPT is critical to identifying practice costs, Prestesater explained.
“I don't care who you are or where you are in health care, everyone has cost pressures,” she said. “No matter what payment model you're in, you have the cost of providing that service, and you have to build a bundle of costs, if you will, to get to a value-based arrangement.”
Alternative payment models are dependent on patient attribution, which is usually “based on where the predominance of care is provided,” Prestesater said.
New models of care
“New models of care are extending the traditional bundle of care provided,” she explained, adding that this includes digitally enabled care models that increase access and patient convenience.
These new models, however, can be challenging to both practices and payers, but Prestesater said the CPT Editorial Panel is rising to the occasion by creating new codes that support new care models that combine multiple encounters—including in-person visits, online virtual visits, texts and remote monitoring—into one bundle for payment.
“You really have to have new ways to manage those models of care as they continue to evolve,” she said.
The AMA-Manatt report goes into more detail about how CPT codes are being developed to reflect new types of professionals who are delivering health care services and how they support new care delivery models with bundled service codes and new types of services.
“The AMA and the CPT Editorial Panel are committed to progressing the code set to ensure it continues to evolve in ways that support the delivery of high-value care to patients and meets the needs of physicians, health professionals, health systems, policymakers and payers,” the report says.
Prestesater echoed this sentiment.
“As the world continues to evolve, the AMA and the CPT Editorial Panel will seek to continue to understand and evolve right along with it,” she said.
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