HOMERuN Collaborative: Hospitalist Advanced Practice Provider Models and Impact of CMS Proposed Billing Rules on Shared Visits Prevention and Management Focus Groups
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The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States. |
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Moderators: Sara Westergaard, Angela Keniston, Anne Linker, Gopi Astik, Greg Bowling, Jeff Schnipper, Kasey Bowden, Marisha Burden
Background: Split (or shared) visits are a CMS policy guideline used to determine whether a physician or advanced practice provider (APP) can bill for services. Per CMS, only one provider can bill for services. This has previously been determined by using history, exam and medical decision making. If an APP bills for services, CMS reimburses at 85% of the physician rate.
Beginning in January 2024, CMS plans to move exclusively to time-based billing where the provider who spends the substantive portion of time (greater than 50%) will bill for services. In anticipation of this change, starting in January of 2023, CMS allows either the previous methodology or the new time-based method to be used.
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How Hospital Medicine Teams Utilize APPs in Patient Care |
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Physician-APP Partnerships: A New Era in Health Care
- Various models employ APPs across a wide range of health care scenarios. Some examples include APPs doing community hospital work, post-surgical patient care, co-management, and independent roles. APPs are incorporated in direct care services, triaging patients, and in some cases taking care of lower acuity cases. They also participate in split shared visits, work night shifts, and take on cross-cover and admission roles. Additionally, APPs are integrated into resident teams and assist in coordinating patient discharges.
- A successful model in many cases was thought to be a collaborative model — there was a perceived value of 15% — only paying 15% more to get two health care professionals seeing a patient, thinking about a patient, and providing care.
- The COVID-19 pandemic accelerated the trend of using APPs in more independent roles, which has been maintained in some organizations due to perceived cost-effectiveness and secondary to continually rising workloads.
- Medical staff bylaws often dictate the extent of physician involvement in patient care. Some models require physician presence, while others allow for more independent APP practice.
- Even in independent models, physicians typically see the patient at some point during their hospital stay.
- Independent practice models can sometimes create tension, as physicians who choose to see some of the APP's patients might be perceived as lacking trust in their APPs. Similarly, independent models can sometimes leave APPs feeling unsupported when they seek physician oversight/collaboration for patient care related questions.
- New billing rules are leading groups to re-evaluate current models.
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"Increasing access to care is the main motivation for using APPs in general ,by freeing up the attendings to see more of the new complex cases, we're driving more in that direction to use our resources more efficiently." |
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Challenges and Considerations in Physician-APP Collaboration
- Balancing billing rules, workload demands, and team culture is crucial in optimizing care delivery models.
- APPs seek diverse patient experiences and do not wish to be limited to simple cases; some groups report utilizing APPs in more limited roles, while other groups do not.
- A team-based culture could be put at risk by the pursuit of "efficiency" and elevated productivity, potentially leading to an increase in independent visits without acknowledging the inherent advantages and effectiveness of team-based care.
- wRVU and financial rules influence care models, with some groups looking to incorporate APPs in the future.
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"One thing that our providers enjoy about our group is that we see all patients regardless of complexity, and seeing the lesser complex patients I worry that will be a dissatisfier to the APPs. Also, if the physicians are asked to see more patients to increase RVUs, I worry that people might leave the institution." |
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How New Billing Rules Might Impact Hospitalist Teams' Approach With APPs |
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- There are financial impacts for some payors whereby APP visits are reimbursed at 85% of the physician bill rate.
- Groups that already have APP autonomy will not necessarily be impacted by new rules, but groups that do shared visits will be impacted, especially because in most shared visit models, APPs may spend more time in patient care activities than MDs. Many groups are still trying to gather more information to build a strategy, i.e., will they have to do fewer shared visits.
- Team-based culture can suffer due to perceived inefficiencies in shared visits and pressure for rapid patient discharge — if team members are doing a visit together it is perceived as slowing things down. The model must be efficient and efficiency takes precedence over collaboration.
- Some of the approach to collaborative models depend on how wRVUs are allocated and incentives such as compensation.
- If the move to time-based billing moves forward, it will require even more education. With this current round of billing changes, it was felt that it likely resulted in less billing from confusion over the rules.
- One discussion point was that because most APPs have the same taxonomy number and if a patient is seen on the same day by two Physician Assistants (PAs) or two Nurse Practitioners (NPs) the charges may bump up against each other and one could be denied for duplicate charges. This depends on whether the payer adjudicates claims by Medicare 2-digit specialty code or by provider taxonomy code.
- Finances will drive these decisions — groups are working to determine financial impact in the various models.
- Some felt that if a physician is involved in the care at all, it should be reflected in the billing. This also highlights the collaborative effort of the team.
- It was noted by some that CMS should allow all of these models and recognize the value (and pay for) collaboration.
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"The work that we do is so time fragmented and interspersed with the care of other patients throughout the day, that the time-based billing makes more sense in an outpatient setting rather than in the inpatient setting. You're always guessing how much time you've spent that day, for that patient." |
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HOMERuN collaborative members shared the following advocacy letters against the time-based billing changes for split/shared visits:
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Key Takeaways:
- APP and physician collaboration is changing in part driven by the pandemic and in part due to perceived needs to increase efficiency and by increasing workloads.
- New billing rules for shared/split visits may drive hospital care models towards independent APP visits, though this is in part determined by medical staff bylaws, state laws, and compensation and incentive structures.
- Team-based culture and patient care was felt to be threatened by these changes. It was noted at some institutions that efficiency takes precedence over team-based culture.
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HOMERuN-Affiliated Study Seeking Partners |
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Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE) Study |
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Purpose of RELIANCE:
Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD.
RELIANCE is Seeking Community-Based Hospitalists:
Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE.
Benefits and Compensation:
- $500/year honorarium for being a community partner (paid after registration) plus $2,000 per patient enrolled.
- Option to participate in clinical roundtables with COPD thought leaders.
- Contribute topic ideas for future grant proposals or publications related to hospitalist care.
- Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.
Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.
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Our next meeting will be on April 14, 2023. |
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Image Attributions: Vector images from vecteezy.com |
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If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.
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