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What is value-based care? How does value-based care work? How to optimize value-based care? What is population health management? What is cost control in healthcare?
Our guest is Lori Prestesater, senior vice president of Health Solutions at the American Medical Association, discusses the evolution of value-based care delivery and the the three pillars of value-based care: population health and quality management, cost management, and alternative payment models. She shares CPT code news and examples of CPT code changes in health care payment models, like the rise of digitally enabled care during the COVID pandemic for telehealth and telemedicine services. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Lori Prestesater, senior vice president of Health Solutions, American Medical Association
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about what success looks like in value-based care and how the AMA's CPT codes can help you get there. Our guest today is Lori Prestesater, senior vice president of health solutions at the AMA in Chicago. I'm Todd Unger, AMA's chief experience officer. Lori, thanks so much for joining us today.
Prestesater: Thank you for having me. I'm delighted to be here today.
Unger: Excellent. Well, before we dive in and talk more about specifically about the interaction with CPT and value-based care, talk to us a little bit about value-based care. It's a topic that comes up again and again in our discussions with many of our health system partners. Why is it getting so much traction right now?
Prestesater: So 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. During the pandemic, we saw a huge influx of digitally-enabled care, right? So it really accelerated, I would say, the path to value-based care. We've been talking about value-based care for a very long time with little progress. We are now seeing a surge of people moving to value-based care and needing to be able to accommodate those new payment models.
Unger: Now, I don't know if I'm wrong here, but when you say value-based care, maybe the first thing people associate, it might not be CPT codes, right? So just give us a high level overview of what that interaction looks like.
Prestesater: Sure. And you're right. It's probably not the first thing they think about. CPT has been the foundation of how we define medical services since 1966, believe it or not. But it's been always associated with a traditional fee-for-service model of care. It really is the standard used to define medical procedures and services. And it fits very well in a fee-for-service model.
However, it also really provides the foundation for value-based care. When you think about the need to do research, clinical research, you have to account for those services. You think about the need to establish a cost, the need to do and support interoperability so that we can have seamless records across different care settings. So CPT is really still a foundational building block as we think about when we move to value-based care.
Unger: Well, let's talk a little bit more in detail. You've created a new report called "Accelerating the Adoption of Value-Based Care." And in that, you outline three pillars of success. Let's start with the first one.
Prestesater: Absolutely. So population health and quality management would be the first pillar. And I'd like to say we established those. But really, I think they're industry standards. CPT is fitting into the industry standard in all ways that we can to support moving care forward.
So really, talking about population health is talking about providing the right care, at the right time, in the right setting, and doing so in a way that can improve quality and reduce cost, ideally preventing expensive downstream events of care. So keeping people out of the emergency room, keeping people out of settings of care when we can, preventative care, and how we do that in a way that's effective for them, for the physician, and frankly, for the payer.
Unger: How can practices or what can practices do to address that particular issue?
Prestesater: So really, most models are built on some kind of attribution model. So a practice has a panel of patients attributed to them using some method. And in order to do that attribution, CPT really provides the foundation that helps to support that attribution, that then can establish the baseline for metrics. How are those patients going to be managed? How are those patients going to be measured? What can we do to increase the outcomes while we manage the cost?
A great example would be Blue Cross Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, who would say they use CPT as the foundation in order to negotiate and manage those value-based arrangements with their physician practices. They can set the baseline for care. They can set the baseline for cost. And then they can identify areas that they might need physician education. They might have areas of improvement or things that they should tweak in the model.
Unger: Now, you mentioned the word cost, which happens to be pillar number two. So why is that so important for success in value-based care?
Prestesater: Well, I don't care who you are or where you are in health care, everyone has cost pressures. And so being able to account for that cost, identify the cost, manage the cost, and then manage improving it is something that is universal. And CPT allows you to, at a detailed level, identify that unit of cost.
Unger: So tell us more about that. Exactly how does that work?
Prestesater: So CPT is the foundational layer to identify a procedure or a service. 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. So you have to budget for that. You have to staff for it. You have to account for it. You have to be able to manage it and measure it. A lot of people use it to do network management to most effectively manage that cost. So CPT, again, really provides that foundational baseline or benchmark to use.
Unger: Now, you mentioned whatever payment model you're working. And in fact, the third pillar does relate to alternative payment model contracting. So what do we need to know about that?
Prestesater: So in almost any of these models, a practice or whomever has to get patients attributed to them. And in many cases, it's based on where the predominance of care is provided, which, again, CPT allows you to track. So you can assign the patients to the right physician, provider, however the panel works or the payment model works.
Now, the other thing, as I mentioned, during the pandemic, we've seen this rise in digitally-enabled care, vendors, models, new models of care that are extending the traditional bundle of care provided. It's increasing access. It's providing patient convenience. But it's also challenging payers and providers to find new models that support a bundle of care that may involve a number of patient encounters that could be digitally-based. They could be self-monitoring. But the bundle of care can be triggered by a CPT code.
So during the pandemic, and even before, the panel evolved a number of new CPT codes to support these new care models and the new way care is being delivered. So a great example would be you trigger a bundle. It may have multiple encounters, but you only want one copay. So you really have to have new ways to manage those models of care as they continue to evolve. And they will keep changing. They'll be refined. And the CPT code set and the CPT panel will need to and have, but will continue to need to evolve to support those new models as they evolve.
Unger: It's so interesting. Just, I guess, the theme of this is adaptation. And part of that is to new care models. Part of it is adjusting to what other pandemic is thrown at us. It's been really informative to hear about that connection. Anything else you want to leave our audience with?
Prestesater: I would just like to say that as hopefully you've heard today and just referenced, 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. So we appreciate the engagement from the community in helping us to learn and evolve. And we continue to be open to do so.
Unger: Well, Lori, thank you so much for being here today. I found that really fascinating, very interesting. And we're going to be sure to include a link to the report in the description of this episode. And I encourage everyone out there to take a look. If you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/join.
That wraps up today's episode. And we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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