The move toward value-based care involves “a reimagining of the traditional definition of health care delivery” with the aim of supporting better outcomes at lower costs, according to a report from the AMA and consultants Manatt Health.
The report (PDF) notes that a decade of performance measures has shown that Medicare Accountable Care Organizations (ACOs) deliver quality care while saving Medicare money. But, despite these metrics, comprehensive adoption of value-based care has been slow, with almost 90% of all U.S. health care physician payments in 2022 having at least a portion tied to a fee-for-service architecture.
“Sustainable adoption of value-based care is proceeding, though considerably more slowly than some of us would've predicted or liked, and the AMA is leading the national conversation on how it can be accelerated,” said Tom Cassels, a managing director at Manatt Health, at the HLTH 2024 conference in Las Vegas.
Cassels served as moderator of a panel discussion sharing practical steps for facilitating digitally enabled value-based care. He added that this acceleration is being propelled, in part, by the AMA Current Procedural Terminology (CPT®) codes.
The AMA is “playing a critical role in supporting the shift to value-based payment through leadership in areas ranging from physician practice adoption to stewardship of the CPT code set,” Cassels said.
Panelist Christopher Botts, the AMA’s senior manager of care delivery and payment, cited the AMA’s work with the health insurer trade group AHIP and the National Association of Accountable Care Organizations to advance sustainable value-based care adoption.
A highlight of that collaboration has been the publication of a playbook of best practices for value-based care payment arrangements (PDF). The playbook offers an in-depth guide to help overcome key challenges in such arrangements.
The report identifies “more than 90 best practices that are really focused on making participation within value-based care arrangements easier, and that will, ultimately, allow physicians and their care teams to focus on what they care about most—which is evidence-based, equitable, coordinated, whole-person care,” Botts said.
The payment best-practices playbook builds on prior work that was focused on improving data collection and sharing within these value-based care arrangements. The playbooks recognize that “time is a limited resource,” said Botts said who cited other common themes in these documents including:
- The importance of available, timely, relevant and actionable data.
- Alignment across different value-based care arrangements to alleviate physician practice burdens.
- Flexibility to support the needs of populations the practices serve.
- Transparency about payment methodologies.
Such transparency “is really critical to creating the trust that’s essential for succeeding under these specific arrangements,” Botts explained.
Opportunities for CPT to evolve
Panelist Zach Hochstetler, the AMA’s vice president of payment and coding, described the findings of the AMA-Manatt report, which includes market perspectives on how the CPT code set is the foundation of value-based care arrangements. The report was drawn from a series of interviews with leaders at health care organizations that provide value-based care, along with those at health plans, integrated delivery systems, health technology organizations and others.
The findings confirmed that CPT plays a foundational role in value-based care around three pillars: patient attribution, budget and benchmark-setting, and identifying patients for clinical interventions.
“There are a couple interesting things that surfaced from this research,” Hochstetler said, and the findings are informing how the CPT Editorial Panel is looking at evolving the code set to better meet the market’s needs.
These findings include:
- New people, such as community health care workers, are providing services and they are not always clearly identified in specific CPT codes.
- New delivery models are focused on bundling episodes of care.
- New types of care are being provided to address social drivers of health.
“Innovative companies and physicians are looking for larger episodes-of-care bundles so that you don't have to understand all the reporting requirements for the different time-based codes,” Hochstetler said.
CPT codes for these bundles could be reported whether care was delivered in person, virtually or via text.
“Rather than have three separate codes for that, can that just be part of a continuum of care?” Hochstetler asked. “Then, typically these value-based care arrangements have the ability to appropriately pay for those services.”
He added that a strategic plan is being developed for review by the CPT Editorial Panel that will look for ways the code set can evolve to address that feedback. That work began last year and will continue in 2025, Hochstetler said.
The report describes these three main areas in which the CPT code set is already helping to advance value-based care:
- 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.
The CPT code set “is a critical enabler of effective population health and quality management, cost management and alternative payment model contracting,” says the AMA-Manatt report.
“As new models of VBC emerge—that involve greater use of multidisciplinary teams, digital tools and high-frequency patient interactions—the AMA and the CPT Editorial Panel remain committed to evolving the code set to ensure it responds to the needs of physicians, health professionals, health systems, policymakers and payers,” the report adds.
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Addressing the digital divide
Cassels cited the “digital divide” as a barrier to value-based care and asked what can be done to enable wider use of digital health tools—especially in areas and populations with limited access.
Panelist Narayana Murali, MD, system chief medical officer of medicine services at the Danville, Pennsylvania-based Geisinger integrated health system, noted that the digital divide is especially acute in rural areas.
Dr. Murali also described how Geisinger has partnered with Best Buy to send the retailer’s Geek Squad tech personnel to patients’ homes to install the digital equipment and teach patients how to use it.
“When we are looking for remote-monitoring or RPM [remote physiological monitoring] devices or any other technology—for example, diabetes, blood pressure and glucose monitors—we want those tools to be Wi-Fi-encompassing—with built in Wi-Fi connectivity and functionality to address the digital divide—so that the patient does not have to struggle in getting that particular piece for a seamless connection,” he said.
Geisinger is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
A former chair of the AMA Integrated Physician Practice Section, Dr. Murali served on the work groups that developed the playbooks for value-based care payment best practices, and he applauded the AMA’s role in accelerating adoption of these types of payment arrangements.
“It's important to also recognize what the AMA brings to the table as a convener,” Dr. Murali said.
“They're focused on the value-based care journey,” he added. “And they're focused on the playbooks that are required to have organizations recognize what are the basic elementary steps that you need to take.”
