Transitioning to value-based care: What physician groups need to know

When it comes to transitioning to value-based care, many physician groups find themselves trying to do it all.

Providers are simultaneously striving to win bonuses in emerging value-based initiatives such as the Merit-based Incentive Payment Systems (MIPS) and other alternative payment models, while continuing to best serve their fee-for-service (FFS) patients.

To succeed under value-based payment models, providers must make fundamental changes in their daily operations that improve the quality and reduce the cost of healthcare. Harder work is not necessary. It just means providers need to work differently. The current emphasis on productivity and maximizing FFS revenue will need to give way to an emphasis on proactively managing comprehensive care and wellness, both physical and behavioral. The successful transition to Population Health Management (PHM) will be the defining characteristic of physician practices and ACOs that consistently claim bonuses and avoid penalties under value-based reimbursement models.

The Centers for Medicare and Medicaid (CMS) has launched initiatives such as Annual Wellness Visit (AWV), Transitional Care Management (TCM), Chronic Care Management (CCM), and Behavioral Health Integration Services (BHI), to smooth the transition to a PHM-based approach to care delivery. By layering these programs into the practice, providers can build a solid PHM foundation with little or no up-front costs. Additionally, these initiatives have the potential to double FFS revenue.

More importantly, these programs can have a significant impact on helping providers improve performance in value-based payment models:

  • In addition to helping to identify at risk patients, AWVs provide an opportunity to bring in healthy patients that can then be attributed to the ACO.
  • AWV, CCM and BHI increase utilization of recommended preventative services to help keep patients well.
  • AWV, CCM and BHI reduce admissions; while CCM and TCM reduce re-admissions.
  • AWV and TCM enroll at-risk patients in CCM and/or BHI.
  • CCM and BHI provide better care management for patients between office visits.
  • The General BHI program, which is essentially CCM for Behavioral Health, helps clinics begins to transition towards more integrative care without significant investments.

Like any population health initiative, succeeding with these programs will take some forethought, cross-functional commitment and strong collaboration from everyone involved. Deploying any of these programs without full commitment from the billing providers will likely end in failure. Additionally, they will require the right workflow process, staffing resources and supporting technology that complements existing EHR systems. Below are key points to know regarding AWV, TCM, CCM and General BHI:


The Medicare AWV is a free, evidence-based preventive service that involves the completion of a health risk assessment and the creation of a personalized prevention plan. Since the launch of the program in 2011, the AWV has been highly underused by both patients and providers. Most patients aren’t aware of the AWV and those who are often get it confused with an ‘annual exam’. Providers have been focused on treating “sickness” since time immemorial. The transition from practicing ‘reactive’ medicine to ‘proactive’ medicine, aka “wellness care” is a significant paradigm shift that will take time to adopt but is critical to impacting both quality and cost over the long run. The AWV serves as a foundational tool in wellness care. Providers who don’t offer the AWV service to their eligible patients are depriving them of the ability to better understand their overall health needs and proactively engage in staying healthy.

The ultimate goal of wellness care is to assess the potential for an avoidable disease state and prescribe evidence-based preventive treatment protocols that reduce the risk of that disease state. Embedded in the AWV is a health risk assessment (HRA). Non-clinical staff can leverage the HRA to gather information from the patient specific to overall level of cognition, memory, mobility, and mental health functioning. The HRA also assesses ADLs, IADLs and risk for falls. Armed with the information gathered from the HRA, the staff can provide counseling to address health risks, such as obesity, smoking, drinking, etc. and the physician can prescribe recommended preventive services, screenings, and immunizations that are not typically provided in any “sickness” office visits.

The most effective way for providers to offer the AWV service with the least amount of disruption to their daily workflow is to structure the scope of requirements into an operational plan that fits the unique needs of the practice. Like any clinical program, success will hinge on having the appropriate staffing, technology and process necessary to support an efficient and profitable program.


In 2013, CMS began paying for transitional care management (TCM) services via two new CPT codes. TCM focuses on providing patients with a seamless transition from a higher level of care (acute) to a lower level of care (non-acute) with the goal of reducing unnecessary acute care readmissions. The service entails an interactive contact with the patient within two business days of discharge, a provider office visit within seven (for complex patients) or fourteen days of discharge and providing care management as needed for 30 days following discharge. TCM is beneficial to patients, practices and hospitals as well. A hospitalization is typically a stressful ordeal for patients. Providing patients and their caregivers with the additional support they need post-discharge can ensure they understand and adhere to the discharge instructions, including medication adherence. For practices and ACOs, TCM can have a significant impact on cost as well as improve both MSSP and MIPS measures. It also provides the perfect time to identify and enroll patients in CCM or General BHI and ensure they’re aware of the AWV service. For hospitals, TCM improves value-based purchasing domain measures.

Like the AWV, the greatest success factor in deploying the program is to ensure the development of a solid operational plan that fits the nuances of the practice. The key TCM workflow triggers include, timely discharge notification and receipt of discharge summaries, appropriate staffing to contact patients within the two-day window, scheduling considerations to accommodate the required office visits, and a mechanism to properly document the scope of service prior to billing the code.


CMS gave chronic care management efforts a boost when it launched a CPT code that offers $42 per member, per month, to providers who engage in 20 minutes of non-face-to-face interaction with qualified patients – having two or more chronic conditions. The service entails providing care coordination and care management between office visits. The new code was a welcomed development for many providers who were already engaged in unreimbursed monthly calls with chronically ill patients. For patients, the CCM coordinator serves as their personal care advocate to help them navigate the complexity of the healthcare system.

In addition to the direct revenue associated with providing CCM services, patients participating in CCM generally end up having more primary care visits per year. Fundamentally, providing better care management between office visits has been shown to drive early PCP intervention that decreases unnecessary high cost ER visits and hospitalizations. Program success is dictated by consistency in enrollment and call practices and ensuring patients derive value from their conversation with an assigned care manager.

The biggest decision for providers interested in launching a CCM program is whether to build and maintain the capacity internally or contract with a CCM vendor to administer the program. There are pros and cons to both approaches and often a hybrid of the two is most beneficial.


One of the biggest hurdles for practices and ACOs as they transition to value-based care is how to measurably and effectively address the high-volume behavioral health needs of their patients. Due to a shortage of psychiatrists and the associated stigma with psychiatric care, behavioral health conditions, including substance abuse, are increasingly treated in the primary care setting. Unfortunately, without a standard of care in place to monitor psychotropic medication side effects and overall treatment progress, the clinical and financial costs associated with behavioral conditions have skyrocketed.

In an effort to close the quality and cost gap between medical and mental health, Medicare launched four new reimbursement codes for Behavioral Health Integration (BHI) in 2017. These codes address the growing need for psychiatric interventions by the primary care workforce and help to establish a path to an integrated, coordinated approach to behavioral healthcare as a whole.

One of those codes, coined General BHI, is a first step approach to behavioral integration and mirrors Medicare’s CCM program with these exceptions; the focus is on behavioral health conditions, including substance abuse, the eligibility criteria is wider, the use of applicable validated rating scales is required, and there’s a higher reimbursement rate.

Physicians now have an opportunity to launch behavioral health integration as a long-term, fundamental part of their practice without making significant investments. The most compelling aspect of General BHI is the ability to simultaneously deploy it with CCM. BHI and CCM combined allow physicians to effectively manage the entire population of their most vulnerable patients while simultaneously aligning with quality improvement measures and creating two new revenue streams for their practice.


AWV, TCM, CCM and General BHI programs have proven to be valuable to both practices and patients, but not with technology alone. Sustainable programs are built with the right people, the right process and the right technology. For more detailed information on these programs, read how to Jump Start Your Transition to Value-Based Care.

Alex Tse, MD, is a primary care provider with over 40 years of primary care practice. He is the chief medical information officer of SmartlinkHealth.

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