The key to success is getting to know your team, according to this CNO.
Jessica “Jess” Almeida’s background in nursing leadership spans a variety of patient care and nonclinical areas. Almeida earned her doctorate in nursing practice and her master’s in nursing from Capella University in Minneapolis, and professionally, she has led hospital-wide initiatives focused on improving communication, interdisciplinary care and operational efficiency.
Almeida joined Cedars-Sinai Marina del Rey Hospital in 2023 as associate director of Nursing Operations, and she now serves as chief nursing officer. She honed her nursing expertise over more than two decades and has extensive clinical experience working with patients in neonatal intensive care units, emergency departments and medical-surgical divisions.
Prior to joining Marina del Rey Hospital, Almeida served as the executive director of operations at Cedars-Sinai Providence Tarzana Medical Center, where she focused on quality improvement projects related to patient flow, work processes, clinical informatics and construction of the hospital’s new patient tower.
On our latest installment of The Exec, HealthLeaders sat down with Almeida to discuss her journey into nursing, and her thoughts on trends in the nursing industry. Tune in to hear her insights.
The company behind the stylish, AI-enabled CarePod has abruptly closed, following a similar spiral as the HealthSpot more than a decade ago. The news proves that healthcare innovators shouldn’t just be trying to recreate the doctor’s office.
Another kiosk-based telehealth company has shut down, proving once again that a high-tech virtual care platform isn’t the successful business model that disruptors think it can be.
Forward, which launched in 2016 with a cash-based model and unveiled the stylish, AI-enabled CarePod just last year, announced its abrupt demise in a company post this week, putting some 200 employees out of work. The company said it was immediately discontinuing its app, cancelling all scheduled visits and shutting down all operations, while keeping a support team available for about a month.
The collapse is reminiscent of the HealthSpot, a similarly-styled kiosk that debuted at the CES show in Las Vegas in 2012. The company behind the kiosk raised almost $50 million, built close to 200 kiosks and had deals in place with Rite-Aid, the Mayo Clinic, Cleveland Clinic and Kaiser Permanente before going bankrupt in 2016.
The lesson to be learned in these closures is that technology alone won’t solve anything, and that consumers and business owners are looking past all the bells and whistles for convenient, no-frills healthcare connections. A kiosk that can replicate a complete visit to the doctor’s office may look and sound great, but it’s still a healthcare visit to a different location. If consumers want the experience to look that much like a doctor’s office, they’ll go to their doctor’s office.
To be fair, the kiosk concept is still enticing. Pursuant Health, which began as SoloHealth in 2007 with the EyeSite vision kiosk, now has more than 4,600 health kiosks in high-traffic retail and grocery stores across the country. And Canada-based UniDoc Health Group, which unveiled its H3 Cube Virtual Care Simulations Model (VCSM) at the American Telemedicine Association conference in 2022, rolled out the first commercial shipment this week, and is pursuing an international “AI-focused eHealth” strategy that would out its kiosks in remote and resource-thin regions around the globe.
Health systems and hospitals are also interested in the form factor. Rochester University Medical Center has partnered with Five Star Bank to locate smaller telehealth kiosks in several bank branches, eyeing a strategy that that improves access in rural upstate New York. And several healthcare organizations across the US have located smaller kiosks--some no more than a laptop and connected devices in a cubicle—in libraries, malls, community centers and other locations with the goal of giving consumers quick and easy access to virtual care providers for small health concerns.
As Forward and HealthSpot have proven, bigger isn’t better and telehealth companies, care providers and disruptors who are looking to recreate the doctor’s office in other settings are missing the point. Small, quick and easy may be the key to sustainability.
As the HealthLeaders 2024 RevTech Exchange kicked into action this week in Nashville, executives from dozens of health systems discussed how they're managing new technology like AI
Today's revenue cycle management leaders need to be agile. The healthcare industry is going through a significant period of change, buffeted by costs and quality concerns and workforce shortages and buffered by new technologies like AI. That's a challenging environment for any leader to navigate.
Roughly 40 RCM leaders from health systems across the country gathered in Nashville this week at the HealthLeaders 2024 RevTech Exchange to talk about those challenges and opportunities.
Here are a few key plot points from the first day of the Exchange:
Train, train, and train some more. And don't stop training. Due in large part to the advances in automation and the potential of AI, the revenue cycle workforce is evolving. Managers need to develop a strategy that prepares staff for that evolution. They need to address that worry that AI is taking people's jobs by pointing out that jobs aren't disappearing, but they are changing. RCM staff will become monitors, overseers and auditors, keeping a close eye on the technology that is doing all the manual tasks they used to do.
And that training won't stop. A key element of generative and predictive AI is that it keeps on learning, and RCM staff will need to keep on learning alongside those tools.
That goes for leaders as well. New technologies like AI are new to everyone, including those in the C-Suite. Healthcare leaders need to have a clear understanding not only of these new opportunities, but how they'll affect staff and workflows. Be ready to talk to people who are worried that AI will replace them, as well as staff who are perhaps a bit too eager to try something new.
Technology isn't the answer. "We look at technology like it's going to solve all our problems," says Derek Dudley, VP of Revenue Cycle Operations at Tidelands Health. "But a $200 hammer isn't going to make you a better carpenter."
As with clinicians, RCM managers need to understand that technology is a tool that will help them become better, but it won't solve all the pressing problems of healthcare on its own. Managers and staff need to understand how to use those tools to improve rev cycle performance.
For example, Beth Carlson, VP of Revenue Cycle at the West Virginia University Health System (WVU Medicine), noted her health system developed a tool to predict denials from a certain payer. The tool was wildly successful—but it was scrapped, because the denials were still happening. In other words, they'd created a great tool, but it didn't have any value.
Look for proactive solutions. Taking the WVU Medicine example one step further, what the health system needed was a tool that would identify the root causes of those denials, and develop a strategy for preventing denials in the first place.
Several health system executives at the Exchange emphasized the need to develop new tools and programs that tackle key pain points in RCM, such as denials, appeals and prior authorization hangups, before they happen. The appeal of AI lies in gathering all the data at hand and predicting when those issues occur, then using that data to plot the best way to avoid them.
Collaborate with IT and especially clinicians. Revenue cycle departments shouldn't exist in their own silos, and yet they sometimes think they do. Because of this, and because many of the sexy new AI tools address clinical care, RCM staff may be feeling a bit inferior to their medical counterparts.
That's a load of baloney. Successful health systems and hospitals thrive on collaboration, and it's important that executives look for those opportunities to collaborate on new tech and programs. Lynn Ansley, VP of Revenue Cycle Management at the Moffitt Cancer Center, said revenue cycle leaders should even go on rounds with clinicians to understand their workflows and see where RCM technology intersects.
In fact, revenue cycle managers should even find clinician champions, much like CIOs and CNOs will do to support the rollout of new clinical technology. Having clinician support and have clinicians understand how RCM technology benefits their workflows will go a long way toward establishing that elusive ROI.
Find that elusive ROI. This is the biggest challenge in healthcare technology today. New tools like AI may look great and even produce amazing results in pilots, but they need to prove long-term value, and that hasn't been easy so far. With health systems and hospitals on razor-thin margins and reluctant to spend money on new ideas (especially something as pricey as AI), there has to be a proven ROI attached.
Balance established tech with new tech. Many healthcare organizations don't have the resources to develop new technology like AI, so they outsource, looking for a company with a good background and product or even a startup that they support. On the other hand, EHR companies are developing their own tools that integrate into the medical record. Is it better to wait for that tool or spend money on an outsourced product that may have to be bolted onto the EHR?
It's not an easy question to answer. Some Exchange participants said they don't want to wait for their EHR provider to develop a tool they need now and are willing to look for help. Others are against bolted-on functionality and are willing to wait. And then there are those who would consider buying a new tool or capability and then switching over when the EHR provider comes along with that tool.
Look at RCM from the outside. Many of the new ideas coming into healthcare have proven themselves in other industries, like retail, banking and travel. And while the healthcare sandbox is a difficult place in which to play with new concepts, savvy leaders will look for ways to adopt them and adapt to the changes. Part of that process includes understanding how these ideas worked in other industries and learning how they might fit in.
Beyond that, RCM leaders also need to look at their departments from the perspective of other parts of the healthcare ecosystem. How does IT see the RCM process? How do doctors and nurses view those operations? This is particularly important when developing a culture of collaboration.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
Workforce concerns go far beyond just recruitment and retention, according to HealthLeaders Exchange members.
Today's CNOs, CMOs, and other industry leaders are confronting AI, breaking down barriers to entry in education, and cultivating a sense safety in the workplace, all in an effort to create the most sustainable workforce possible. However, this work doesn't come without major challenges.
The 2024 HealthLeaders Workforce Decision Makers Exchange wrapped up last week in Washington D.C. after two days of insightful idea-sharing and compelling discussion about the most difficult obstacles in building a workforce.
Here are three key takeaways that leaders should know about workforce challenges.
The standard workforce challenges persist while others continue to pop up, according to this nurse leader.
On this episode of HL Shorts, we hear from Katie Boston-Leary, senior vice president of equity and engagement at the American Nurses Association (ANA), and HealthLeaders Exchange member, about the hottest workforce challenges that CNOs are facing right now. Tune in to hear her insights.
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
Recruiting alone won't solve the workforce crisis, according to these leaders.
One of the biggest areas of concern for healthcare executives of all titles is the workforce, and the issues go far beyond recruitment and retention.
Today's CNOs, CMOs, and other industry leaders are confronting AI, breaking down barriers to entry in education, and cultivating a sense safety in the workplace, all in an effort to create the most sustainable workforce possible. However, this work doesn't come without major challenges.
The 2024 HealthLeaders Workforce Decision Makers Exchange wrapped up last week in Washington D.C. after two days of insightful idea-sharing and compelling discussion about the most difficult obstacles in building a workforce. Here's how leaders are tackling the key issues that are keeping them up at night.
Leveraging AI and virtual care
First and foremost, the healthcare industry is facing a workforce shortage, of nurses, physicians, and plenty of other critical positions. However, according to the Exchange members, it's not just about hiring new people.
"We cannot recruit our way out of the workforce crisis," said Chris DeRienzo, MD, chief physician executive at the American Hospital Association (AHA).
Leaders need integrate technologies such as AI and virtual nursing to streamline processes and give clinicians time back at the bedside. However, both of those technologies should be used as assistive tools, not replacements for FTEs.
When it comes to AI, leaders should strive to implement and adopt AI that has a low barrier to entry and can be used by clinicians with varied technological backgrounds. Staff must be included in the development process, and patients should be fully informed and educated on the technology and how it works. Leaders should consider using patient advisory boards to understand the questions and concerns that patients have surrounding AI as well.
For virtual care, specifically in nursing, leaders should consider using metrics such as retention rates, turnover rates, and nurse engagement to measure ROI. The capabilities of virtual care technology stretch far beyond only virtual nursing, and health systems should consider how other departments can leverage the same technology for different purposes.
Cultivating generational wellness
It's also no secret that workforce expectations have changed in recent years, especially since the pandemic. New generations of nurses and physicians want different things and prioritize other types of benefits than previous generations before them. Younger nurses want more flexibility, work-life balance, and with the rising cost of living, more compensation with benefits that suit their needs.
For leaders, according to the Exchange members, it's crucial to let go of some of the more traditional processes and make way for new ones. The idea of flexible scheduling has been gaining traction, especially since the pandemic, as a method of accommodation for the busy lives of nurses at all life stages.
The Exchange members also emphasized the importance of wellness and building a culture of psychological safety, where staff feel comfortable approaching leadership with questions and concerns. Leaders have a responsibility to connect with their employees and build relationships that allow for honest communication and trust.
Building educational pipelines
One of the biggest drivers of the workforce shortage is the lack of clear pathways into the healthcare industry.
According to the Exchange members, this begins with a faculty shortage. The lack of teachers and faculty limits the number of slots available in medical school programs, which in turn limits the number of applicants who can be accepted into the programs. Medical education is also expensive and time consuming, and with stagnating wages, future physicians are wondering whether the profession is worth it.
Leaders must strategize and build better pipelines into the industry, for both physicians and nurses. According to the Exchange members, this involves strong partnerships with academic institutions as well as considering innovative solutions such as tuition reimbursement or assistance, and other incentives for students who are interested in entering the industry. It's also important that leaders keep diversity in mind and build workforces that reflect the communities they serve.
Ultimately, leaders need to keep experimenting with new ways to recruit and retain clinicians, streamline processes, and expand how care is delivered. According to Ronda McKay, vice president of patient care services and chief nursing officer at Powers Health, even if things go wrong, it energizes leaders and staff alike when they can try new things.
"If we don't think it's going to hurt anybody," McKay said, "try it."
See more coverage from the 2024 Workforce Decision Makers Exchange here.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
In this HealthLeaders podcast, Jim Blum, CMIO at University of Iowa Health Care and a Mastermind participant, talks about giving clinicians the tools to improve their workflows and patient care without hitting them over the head with governance.
Is it possible to do too much with AI governance?
James Blum, MD, thinks so. The CMIO at University of Iowa Health Care and a participant in the HealthLeaders Mastermind program on AI in clinical care, says the technology needs to be treated with the proper safeguards, but that doesn't mean separating it from all other innovative tools and processes.
"AI and healthcare probably shouldn't exist in the vacuum," he said during a recent HealthLeaders podcast. "And we shouldn't be acquiring AI for the sake of AI. We should probably be looking to solve problems that people have, and if that involves AI, great. If it doesn't, that's probably in many ways better because it takes out display of governance and potentially a lot of additional expense."
UI Health Care has launched two AI tools for clinical care: An ambient transcription platform developed by Nabla, which roughly 1,100 of the health system's 3,000 doctors are now using, and a chart mining platform from Evidently that collects all relevant data on a patient from multiple sources to give clinicians a concise view of the patient.
"I can see these very sick patients [with] long, complex medical histories and, really, I'm able to know as much about that patient as the intern that was up all night trying to comb through their entire medical history," he points out.
Blum says both tools were carefully reviewed by UI Health Care through a normal process for reviewing new vendors. With AI, that includes bringing in clinicians and IT personnel who understand the nuances of the technology.
"It is with a group of individuals that are qualified to review the AI right and really understand the performance characteristics and what can be expected of the technology in addition to our typical acquisition process," he said.
"And that's where the AI committee can get engaged and say, ‘OK. Let's look at the performance characteristics and training set and those types of things and give a thumbs up or thumbs down' as to [whether] they think the science behind the AI algorithms is good. And if it's not, then convey that to the groups that are doing the acquisition and say we really don't endorse this because we think it's not a product that's really going to deliver what they're purporting it will deliver to you."
Blum says AI is such an intuitive technology that it doesn't need the intensive resources and training for adoption that health systems typically set aside.
"With all types of departmental meetings and going to individual clinics and a lot of hand-holding … we would we would get nowhere near this level of adoption this quickly if we did it the way we typically roll out," he said.
Instead, with the ambient dictation tool, the health system held one training session and made that available on video. This takes the pressure off of the IT department and gives clinicians more of a responsibility to understand how AI will work for them.
"If it's not working for you, go back and do things [the old way}," he said. "So you don't need to have this really comprehensive, elaborate rollout and you can go ahead and basically turn the technology on and let the use of it grow organically."
"It's a much more targeted intervention and I think results in a much greater utilization," Blum added, noting the health system can identify who isn't using the new technology and help them if needed. "We're not going to go ahead and force you to use the technology you don't want to use, and we're also not going to spoon-feed you. But if you want to be better, you want to be more efficient, it takes a little bit of self-motivation. How many people went to a class on how to use their smartphone before they started using it?"
Blum says he's excited to see how generative and predictive AI evolve and are worked into the clinical space. And while UI Health Care is always looking for new partnerships, the health system will balance doesn't want to buy or build a new tool that will be rendered obsolete by a new capability from its EHR partner in a few years.
More important, he said, are the cost and data storage concerns that come with AI.
"All this stuff, all these large language models and all this processing and the tokenization just requires a ton of computational power," he said. "And this introduces an entire new realm of expense for health systems, without there being necessarily a great financial upside on these things."
Blum says health systems will have a hard time defining an ROI that will please everyone. AI might be great at reducing physician stress, but is that enough for CFOs and CEOs who want the health system to meet increasing patient demands?
"This leads to millions of dollars a year that you're spending on these types of technologies and you may not see a financial upside for that," he says. "And in this era of 1% margins, this gets to be a real challenge."
To listen to the HealthLeaders podcast, click here.
The HealthLeaders Mastermind program is an exclusive series of calls and events with healthcare executives. This Mastermind series features ideas, solutions, and insights on excelling in your AI programs.
To inquire about participating in an upcoming Mastermind series or attending a HealtLeaders Exchange event, email us at exchange@healthleadersmedia.com.
CMS won't extend certain key pandemic-era waivers any longer, putting telehealth expansion plans in jeopardy. Will lawmakers step in and take action?
Pandemic-era telehealth waivers that allowed providers to expand their virtual care footprint will end this year unless Congress takes action.
The Centers for Medicare & Medicaid Services (CMS) announced in its finalized 2025 Physician Fee Schedule that it won’t extend most of those waivers any longer, putting back in place pre-COVID telehealth limitations. Those include restrictions on where telehealth can be provided and delivered, as well as who can use telehealth through Medicare.
The end of the waivers would curtail a number of telehealth strategies, especially for older Americans and those living in urban and suburban areas. It would also limit the use of virtual care by specialists and other types of care providers (such as physical and occupational therapists and speech language pathologists) and limit where telehealth can be provided to certain CMS-approved sites, like health clinics.
CMS has, however, included some changes in telehealth regulation for the coming year, including a one-year extension of the waiver allowing providers who bill Medicare for their services and deliver virtual care from their homes to list their practice as the site of telehealth delivery.
“Allowing appropriately licensed and credentialed providers to practice telehealth from their home improves patient access to healthcare services, reduces healthcare costs, while maintaining and meeting patient demand for care,” advocates said in an October letter to CMS Administrator Chiquita Brooks-LaSure. “This was necessary during the height of the COVID-19 pandemic and remains just as important today amidst provider workforce shortages and burnout, given that 78 percent of health care practitioners agree that retaining the opinion to provide virtual care from a location convenient to the practitioner would ‘significantly reduce the challenges of stress, burnout, or fatigue’ facing their profession and eight in 10 indicate that this flexibility would make them more likely to continue providing medical care.”
In addition, CMS is:
Finalizing a proposal to add several services to the Medicare Telehealth Services List, including caregiver training services on a professional basis and PrEP counseling and safety interventions on a permanent basis. For CY 2025, the agency will continue to suspend limits on the frequency of subsequent inpatient and nursing facility visits and critical care consultations.
Making permanent a ruling that Medicare telehealth services delivered to patients in their home can be done by two-way, real-time, audio-only communication technology (such as a phone) if the patient doesn’t have or want access to video services and the provider can offer that platform.
Making permanent a new definition of “direct supervision” for certain services that are required to furnish under the direct supervision of a physician or other supervising practitioner. The new definition would allow the supervising physician or practitioner to use real-time, interactive, audio-visual communications. For all other services, CMS is extending the use of supervision by telemedicine for one year.
Extending for one year a policy to allow teaching physicians to use telemedicine for purposes of billing for services furnished involving residents in all teaching settings, but only in clinical instances when the service is furnished virtually (such as in a three-way telehealth visit involving the patient, resident and teaching physician).
Led by the ATA, telehealth advocates are holding out hope that Congress will take action on one or more of several bills currently before lawmakers. They include:
The Bipartisan Telehealth Modernization Act of 2024 (R. 7623 and S. 3967) and the CONNECT for Health Act (H.R. 4189 and S. 2016), which would extend Medicare telehealth flexibilities through 2026.
The Telehealth Expansion Act (1001,HR 1843), which would permanently allow individuals with HDHP-HSAs to access telehealth services before meeting their deductible.
The Medicare Telehealth Privacy Act of 2023 (HR 6364), which would make permanent the provision allowing providers to bill for telehealth services using their practice address rather than their home address.
The Telehealth Benefit Expansion for Workers Act of 2023 (HR 824), which would permanently classify telehealth as an excepted benefit, enhancing access for workers.
Despite the promises of AI, there are still some major hurdles, according to executives attending the HealthLeaders Workforce Decision Makers Exchange.
No matter the size of the health system, AI is top of mind for healthcare leaders.
Health systems across the country are at different points of implementation. There are many factors to consider, so while some are ahead of the curve and in the implementation stages, others are still deciding if the investment in AI is what’s best for their workforce.
The HealthLeaders Workforce Decision Makers Exchange is well on its way this week, with participating members discussing the hypotheticals and realities of AI in healthcare and what this new technological revolution means for the workforce.
Here are three major AI hurdles that CNOs, CMOs, and other healthcare leaders will have to overcome.
Implementation to adoption
One of the biggest challenges with implementing any new sort of technology is adoption, and the same goes for AI.
According to the Exchange members, it can be easy to make the investment in new technologies and then not actually adopt them into workflows. CNOs and other leaders must communicate with staff about the presence of AI in their daily operations and educate them on how to integrate the technology into their tasks.
One major goal for health systems using AI is to reduce administrative burden and give time back to clinicians. It is critical that AI and other new technologies have a low barrier to entry, so that staff with different levels of technical literacy can be easily trained.
Staff buy-in
For AI implementation to be successful, the process must include the nurses and physicians who are going to be using it. However, AI has caused quite a bit of fear among staff, in other industries as well as healthcare.
The Exchange members emphasized the importance of communicating to staff that AI is a tool, not a replacement. Leaders must include staff in the conversation from the beginning and be transparent about how their jobs will change. The language being used surrounding AI matters, according to the Exchange members, and leaders must unify the narrative so that internal messaging is communicated clearly.
Patient acceptance
Consistent external messaging is also critical to successfully using AI. Patients must have confidence in their care team. According to the Exchange members, this begins with robust patient education.
Leaders must build trust with patients by explaining how AI and other technology is used and how it will benefit them. Patients need to have a clear idea of what information is being documented and how. The Exchange members also recommended using patient advisory councils to find out what questions or concerns patients might be having about how AI is used.
Stay tuned for more key takeaways from the 2024 Workforce Decision Makers Exchange.
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
Please join the community at our LinkedIn page. To inquire about attending a HealthLeaders Exchange event and becoming a member, email us at exchange@healthleadersmedia.com.
New Advanced Primary Care Management codes will give providers more incentives to use virtual care and digital health to improve care management and coordination.
A new primary care model that allows providers to use virtual care and other technology to address patient care needs is getting the green light from the Centers for Medicare & Medicaid Services.
In the finalized 2025 Physician Fee Schedule unveiled last week, CMS included three new HCPCS codes for Advanced Primary Care Management. The codes, which take effect at the beginning of 2025, focus on physician interactions with patients at the time and place of their choosing and are billed monthly, rather than based on a specific number of minutes spent with a patient.
In a blog post earlier this year, Carrie Nixon and Kaitlin O’Connor of Nixon Gwilt Law said the new codes focus on specific activities by clinicians and using technology to address patient needs.
“The Advanced Primary Care Management (or APCM) HCPCS codes bundle elements of the existing Chronic Care Management (CCM) and Principal Care Management (PCM) codes set with Communications Technology-Based Services (CTBS) codes for virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults to create what CMS refers to as an ‘enhanced care management’ bundle,” they wrote. “Unlike CCM and PCM services, the APCM codes are not time-based – meaning, care management services that do not meet the 20 or 30-minute requirements for CCM or PCM would be billable under APCM.”
Nixon and O’Connor also noted that CMS is expanding the rule to allow non-physician care providers, such as nurse practitioners and physician assistants, to order and bill for those services, as long as any practitioner who bills for those services “Intends to be responsible for the patient’s primary care and is the continuing focal point for all needed healthcare services.”
In a November 5 blog, Alexandra Shalom, senior counsel with the Foley & Lardner law firm, noted that because the new codes were designed to be consistent with existing codes for care coordination, providers need to be careful not to bill the new APCM codes alongside those overlapping codes. Examples of overlapping services include interprofessional specialist consults, remote evaluation videos and images submitted by patients, virtual check-ins and communications with patients through an online portal.
The three new codes are:
G0556: Level 1, for persons with one chronic condition.
G0557: Level 2, for persons with two or more chronic conditions.
G0558: Level 3, for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary.
In a fact sheet issued on November 1, CMS said it had received many requests to increase the valuation for the codes, and will be doing so for G0556.
“Beginning January 1, 2025, physicians and non-physician practitioners (NPPs) who use an advanced primary care model of care delivery as described by the service elements of the APCM codes could bill for APCM services when they are the continuing focal point for all needed health care services and responsible for all the patient's primary care services,” the agency reported. “This new finalized coding and payment better recognizes and describes advanced primary care services, encourages primary care practice transformation, helps ensure that patients have access to high quality primary care services, and simplifies billing and documentation requirements, as compared to existing care management and communication technology-based services codes.”
“The finalized codes also represent a step towards paying for primary care services with hybrid payments (a mix of encounter and population-based payments) to support longitudinal relationships between primary care providers and beneficiaries, by paying for care in larger units of service, and also help drive accountable care,” CMS added. “A practitioner who is participating in a Shared Savings Program ACO, a Realizing Equity, Access, and Community Health ACO (REACH ACO), a Primary Care First practice, or a Making Care Primary practice may satisfy requirements for these codes by virtue of meeting requirements under the Shared Savings Program or Innovation Center model.”
According to Salom, providers seeking reimbursement under one of the three new APCM codes need to satisfy nine requirements:
Patient consent (inform the patient of the services, their right to stop, and of the potential cost sharing obligations;
Initiating visit (required for new patients and patients not seen by the practice in the last three years);
24/7 access and continuity of care (access to team member for urgent needs at all times and continuity through the use of a dedicated team member);
Comprehensive care management (systematic needs assessment, system-based approaches to ensure preventative services are provided, and medication reconciliation, and oversight of patient self-management of medications);
Patient-centered comprehensive care plan (the plan should be timely available to those involved with a patient’s care, routinely updated, and provided to the patient and/or caregiver);
Management of care transitions (ensuring timely exchange of electronic health information and patient follow-up after emergency room visits and hospital discharges);
Practitioner, home-, and community-based care coordination (coordinated referral management with specialists and other health care organizations through developing processes and procedures in the form of collaborative care agreements and electronic consultations);
Enhanced communication opportunities (for patients and caregivers to communicate with team members through additional asynchronous methods);
Patient population-level management (manage preventative and chronic care for the practice’s patient population and develop and implement strategies to improve outcomes); and
Performance measurement (quality, cost of care, and meaningful use of certified electronic health records technology).
“While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing,” Shalom concluded in her post. “HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.”
