By Kent Locklear, MD

You have undoubtedly seen or even personally experienced the devastating financial effects that COVID has created for primary care providers (PCPs) across the nation. Despite routine chronic and preventive medical care remaining essential, some publications estimate upwards of a 6070% reduction in primary care visits since states implemented stay-at-home orders. As a result, practices have furloughed employees (45%), deferred or skipped salaries (28%), or temporarily closed (14%). The totality of impact has been estimated to be as high as $15 billion.

The result of the sudden and dramatic interruption in normal care delivery is the creation of two significant gaps in the system: (1) the gaps in care created by cancelled and delayed visits and procedures, and (2) the financial shortfalls that will be difficult to fill without a change in strategy and day-to-day operations.

We are all seeking effective, efficient ways to address these COVID-related issues while adjusting to a health care system that includes a mix of telehealth services and a thoughtful, measured return to face-to-face care delivery. Fortunately, there are a set of well-established Medicare programs that we have long considered part of the population health tool kit. Further, they can be deployed in a manageable way and are proven to address both the care and quality gaps while serving as a potent source of revenue generation. These programs are Chronic Care Management (CCM), Transition of Care Management (TCM), Remote Patient Monitoring (RPM) and Annual Wellness Visits (AWV).

CCM, TCM and RPM are remotely delivered services available to a subset of qualified Medicare patients intended to enhance patient engagement, improve outcomes and reduce expenditures. CCM services are available to patients with two or more qualifying chronic conditions and can be provided on an ongoing basis following a typical set of regulations governing care delivery and reimbursement.

TCM is a program designed to facilitate the smooth transition of patients back into the home following a hospitalization. The obvious goal is to prevent 30-day readmissions, but the true value is much greater. There are so many opportunities to improve care during these transitions including accurate medication management, caregiver education and support, and ensuring timely follow up and care coordination.

Lastly, the RPM program enables you to keep a pulse, literally in some cases, on your at-risk patients between visits in a manner that assists in the early detection of warning signs for intervention pre-hospitalization. All of these programs can be delivered by care team members such as nurses and care managers working under the supervision of the PCP.

AWV, on the other hand, is a program designed to engage a much broader Medicare population and  serve as a comprehensive annual preventive service review and health risk assessment. Like CCM, TCM and RPM, the majority of the AWV can be conducted by care team members other than the PCP. Recent COVID-related adjustments to accommodate expanded telehealth services allow for the AWV to be conducted via secure video chat. AWVs enable the practice to accomplish a number of important care services simultaneously, including quality gap closure and  satisfying attribution requirements for those healthy elderly who might not otherwise see their PCP during the program year.

So, how do these programs help address the staggering revenue shortfalls we are encountering in 2020 and meaningfully supplement revenue in a typical year?

The typical PCP treats roughly 1,800–2,000 active patients. Assuming a 30% Medicare payer mix, that works out to be 540–600 total active Medicare lives. Using reasonable assumptions* for program eligibility, the average PCP with 500 Medicare patients has an estimated opportunity of over $50,000 annually. To reiterate, these programs also demonstrably reduce overall cost of care and add minimal burden to PCPs.

*Assumptions:

  • AWV: $450 average reimbursement (includes ancillary services, excludes risk adjustment)
  • CCM: 60% eligibility, 50% enrollment, $43/patient/month reimbursement for CCM
  • TCM: 25% of Medicare population admitted at least once annually
  • RPM: 10% overall enrollment, $136/patient in the first month; $115/patient for the second and subsequent months

Given the slowdown in face-to-face visits during the COVID pandemic, innovative providers are embracing the programs covered above and incorporating them as steady revenue sources that will continue to provide benefits to care quality and the bottom line well beyond the public health crisis.

Resources

The Commonwealth Fund | The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges

Fierce Healthcare | Primary Care Practices Could Close in a Matter of ‘Weeks not Months’ Without Financial Support

HCP Live | Primary Care Practices Expected to Lose Billions in Revenue from COVID-19

Lightbeam Health Solutions | Care Management Program Acceleration

About the author: Kent Locklear is chief medical officer of Lightbeam Health Solutions, an ACOFP partner delivering population health management solutions to at-risk providers nationwide.

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