Better Together: Physician-Lead, Team-Based Care

Working as a team is unquestionably the best and most efficient way to maximize the skill sets of a specific group of people. In medicine and depending on the particular needs of the practice, a team-based approach can include various combinations of physicians, nurses, physician assistants, pharmacists, social workers, case managers and other health care professionals. The unique strengths and perspectives of each team member are an asset when providing the safest, best possible care to patients. The best place for physicians to learn how to work as a team is while they are still in training.

“So in a residency world, the team in a hospital setting is going to be the attending physician, usually one or two upper-level residents, and then usually two first-year residents. And in this setting, we have a couple of medical students. That’s our team,” explained Tom Kincer, M.D., Director for the Montgomery Family Medicine Residency Program. “The way that team works in the hospital setting is built on varying levels of responsibility so that as students and residents gain more knowledge and more skills, they’re given more independence yet have oversight of upper levels. So the first-year residents have oversight by the upper-level residents, and the upper-level residents have oversight by the faculty physicians.”

According to Dr. Kincer, the Montgomery Family Medicine Residency Program’s success has been built on this hierarchy of educational independence that has worked for many years and allows for a “symbiotic relationship” between a  mix of disciplines in health care that is patient-centric but always led by a physician. For Dr. Kincer, the ultimate goal of a physician-led team-based model of care will always be to affect change in the health of the population. To do this, there are numerous hurdles to overcome.

“So the team-based model for population health is the best model for patient care,” Dr. Kincer said. “When it comes to providing that one individual patient the best care possible because they can have a physician, right? They could have the physician, lead nurse practitioner, or the pharmacist, or the social worker, or the occupational therapist. All of that is part of the bigger team, but the problem comes in a fee-for-service model with MACRA. How do we pay for all that? Physicians can’t afford to pay for everything out of their pockets, because there’s no direct reimbursement. Once we tackle that, I don’t think we can move forward with a true team-lead model. But it doesn’t exist unless you’re in a health care facility that’s willing to sponsor this team-based model. There are too many competing forces against it.”

While it may appear that the deck is stacked against the physician-led team-based model, as Dr. Kincer noted, if there is a health care facility willing to sponsor it, the advantages to the community are overwhelming.

Perhaps the most frustrating stumbling block in modern medicine today is access to care. For patients who do not have a physician of their own, these patients will use a hospital’s emergency department for all the wrong reasons. Not only does this cause lengthy wait time for patients who need emergency services, but it creates billions in health care treatment costs over time for the hospital. Dr. Kincer’s solution? Spend some money to save not only money but also lives in the long run.

“It’s very difficult for a private practice, primary care physician to have a team-based approach in their office. Other than maybe the physician, a nurse practitioner and their staff. In that model, people need to work to their highest level. So the physician needs to be taking care of patients that require that expert level from the physician, and the nurse practitioner needs to be working at their level and so on to allow the physician to work at their highest level. All this allows the staff to do some of the things the staff needs to do, whether that’s teaching the staff how to apply for drug assistance programs, or to have patients come in and monitor without them actually having to see the nurse practitioner or their physician. If the physician or the nurse practitioner is not seeing the patient, they’re not generating income. There’s got to be enough volume going through the physician and the nurse practitioner over the PA to be able to generate an income to run the office,” Dr. Kincer said.

In an employed physician model, it begins by playing to the institution’s strengths and weaknesses. If the revenue in one department is higher than another, there needs to be a fundamental understanding that the institution can’t work without all departments at the top of their game, so it comes down to budgeting.

“After you find out what the goal of the organization is, you can utilize your resources better for a stronger team-based care model. Certain parts of that model are profit-creating and other parts are patient-oriented that don’t really make the profit, but you can still support the whole team. That’s how most residency programs function as part of the bigger system,” Dr. Kincer said.

The model he created for Baptist Health to use for the Family Medicine Residency Program in Montgomery is called the Care Advisor Program. By identifying a specific group of 250 patients from the tri-county area with chronic illnesses and no insurance who tend to use the emergency department instead of a regular physician to monitor their health issues, the program instituted a team-based model and brought them into their office. Here, patients have access to physicians, nurses, social workers, pharmacy, labs, x-rays, etc., at no cost.

“What we’ve been able to do in our Care Advisor Program in the past 10 years is to save our hospital system about $6 million a year by providing these patients with free medical care. However, it cost us about $4 million a year to take care of this population, but in return, it saves us $6 million a year because prior to the program, it cost the hospital $10 in ER visits to take care of this population that was uninsured. Now with our team-based approach out of the residency program, which is run very efficiently, we’ve taken the average number of ER visits and hospitalizations combined for each patient from 10 to 12 visits a year to less than one per year. The patients get their care in the office, their medications, and follow-up care. We’ve cut expenditures and improved the health of all these patients. The average patients stay in the program for about two years, and their health is improved. Now THAT is population health,” Dr. Kincer said.

Outpatient Visit Evaluation & Management Changes for 2021

For more than 25 years, the American Medical Association has utilized the 1995 or 1997 guidelines for Evaluation and Management (E/M) services in the Current Procedural Terminology (CPT).  The E/M codes have expanded over the years but until now, there has been no update to the elements, in which, we choose a level of service. The Centers for Medicare and Medicaid Services in partnership with the American Medical Association (AMA) collaborated on changes to reduce the administrative burden in documenting outpatient visits for new and established patients.  

The revised guidelines pertain to the new patient codes 99201-99205 and established patient codes 99211-99215.  The revision was announced as part of the 2020 Physician Fee Schedule but does not occur until 2021 due to the many preparations to support this endeavor. The AMA is actually updating the code description for the specified codes, which affects all carriers, not just CMS.  The 99201 code is eliminated for 2021; the remaining codes will retain reimbursement for each code, which is a change from the proposal to condense some codes to a combined rate.  

The inclusion of time has been an explicit factor in the definitions of E/M services in the CPT codebook since 1992.  Beginning in 2021, with the exception of 99211, time alone may be used to select the appropriate level of service. For coding purposes, total time includes both face-to-face and non-face-to-face time spent by the physician or other billable healthcare professional the day of the encounter.  Total time does not include staff preparation time.  

Physician or other provider professional time includes the following:

• Preparing to see the patient (review test, past visits)
• Obtaining or reviewing separately obtained history
• Performing a medically appropriate exam
• Counseling and education for the patient/family
• Ordering medication, tests or procedures
• Referring and communicating with other providers
• Documenting clinical information 
• Independently interpreting results (not separately reported) and communicating results
• Care coordination

Another option for choosing the level of the new or established E/M in 2021 is medical decision-making.  Medical decision-making has always been an element in the level of each new and established visit but never as a standalone element.  The concept of MDM does not apply to CPT 99211. When using MDM in selecting the level of the visit, the documentation should reflect the number and complexity of diagnosis addressed in the encounter.  The amount and complexity of data reviewed or analyzed is also required. The risk of morbidity should be documented to support the level of medical decision-making.  

These changes will most likely reduce the administrative burden for all specialties, but it is also disruptive.  The implementation of electronic medical records has had a huge impact on workflow at the physician/provider level as well as the staff.  Large and small practices have spent time developing comprehensive templates, triage teams, scribe teams, etc. to reduce the physician burden and feed quality data to the EMR.  Each practice will need to analyze the process in which they prepare a patient and how they decide medical necessity of history obtained. Each provider has a different patient schedule; in the past time spent with the patient was explicit.  In 2021, billing on total time spent could send a message of compliance. If a provider sees 25 patients a day coding a level 4 visit, they would be stating they spent 49-60 minutes per patient or 20 hours on that date of service inpatient care.  I do not anticipate providers seeing a higher volume of patients will bill on total time, it is not a common practice for providers to assess time spent with each patient.  

Most providers will probably code using the medical decision-making component. In the past, providers could reach a level 4 established visit based solely on the history and exam, which is not so in 2021! There will be prolonged service codes available to bill in addition to a new or established visit in cases when extended direct patient time is spent with clinical staff and supervised by the physician. 

Managers will spend 2020 assessing the many facets to consider the 2021 changes.  How will they maintain quality data entry in the EMR without the many clicks feeding the data?  Providers may use voice recognition to transcribe the medical decision-making as they did before the EMR.  In a potentially massive cost rebalance, CMS also finalized the relative value units (RVU) for the group of oft-used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most-reported E/M code – from $109 to $136 per claim, a 25 percent increase. Rates for 99213 would jump nearly 30 percent.  

Changes could occur before 2021, but it’s not likely we will move totally away from the decisions already made by CMS and the AMA.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.