Opportunities from the coding changes in primary care [PODCAST]

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“There’s a new best practice emerging, one that lets you deliver a high standard of care today but that well-prepares you for a shift to value. We’ve been talking about it throughout this article series in terms of doing more with less and making the system work for you: it’s group coaching combined with remote patient monitoring. And, based on the coding changes and expanded reimbursements, the data show that patient outcomes are vastly improving under this new model.

The conclusion: It’s time to expand and modernize your practice by offering group coaching services and having your patients’ commercial insurance, Medicare, or workers comp pay the bill.”

James Maskell is a health care executive.

He shares his story and discusses his KevinMD article, “Get familiar with the 2021/2022 coding changes.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have James Maskell. He is a health care executive, and he wrote the KevinMD article “Get familiar with the 2021/2022 coding changes.” James, welcome to the show.

James Maskell: Hey, great to be here with you, Kevin. Thanks for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where we are today?

James Maskell: Yeah, so look, I grew up in England. I did health care economics at university, and in my studies I saw that whether I was looking at the future of England or the U.S., in both countries, with very different medical systems, we were going to head over a cliff in my lifetime, where essentially both countries would run out of money servicing chronic disease. Essentially, the cost was exploding at an exponential rate, and it was chronic disease driving it. At the time I had a job as an investment banker, and I quit, really to dive in, and this was 17 years ago, to the front lines of health care in America, to really understand the root causes of chronic illness and to try and find a path toward solving that key problem.

Kevin Pho: All right. From your view as an economist, what would you say are some of the major drivers that are causing our health care system to consume almost 20 percent of our GDP?

James Maskell: Well, I mean, the long and short of it is that if the majority of people have a chronic illness that is then medicated for the rest of their lives, you can see that each one person’s own cost explosion becomes a whole society’s cost explosion. And the numbers on chronic illness keep getting worse, even though lots of effort is being put into understanding what it is.

In the first job that I had in America, I actually saw people with chronic illness reverse a chronic illness, right? They went from having an autoimmune disease or having type 2 diabetes, and not in a week, but over three months, six months, nine months, 12 months, with a new, empowered operating system for medicine where the patient was participating in their care. I saw people reverse their chronic illness, and that was the first step on the journey.

So I think what exists at a society level is just made up of what’s happening at a personal level. You can imagine, and I’m sure many of your listeners and doctors understand, that if someone’s diagnosed with an autoimmune disease, if they take Humira, in three years they’re taking five drugs, and their care costs $100,000 a year. If that keeps getting worse, it’ll cost $250,000 a year. You get enough of those people stacked on top of each other, and you have a cost explosion.

Kevin Pho: All right, let’s transition into the KevinMD article that you wrote. It’s titled “Get familiar with the 2021/2022 coding changes.” We do have an audience of clinicians here, and we certainly are very interested in a lot of the coding changes. As you know, a lot of clinicians, we don’t have a lot of formal training when it comes to coding, so sometimes these changes are a little bit arcane to us, but it really makes a huge difference in our bottom line. So for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

James Maskell: Yeah, so look, I mean, I’ve been passionate for the last 17 years about what I would call the evolution of medicine, right? How does medicine now adapt to these chronic conditions? When the medical system that we have was really formed and organized, it was really built around acute illness, and now we have a lot of chronic illness, and the etiology and the way that those diseases come about and expand and progress is very different.

So for the last 16 years, I’ve been helping doctors think through how you reorganize your practice around some of these chronic conditions. How do you think about technology? How do you think about workflow? How do you think about different personnel in the office? Does it make sense to have nutritionists and health coaches and other people that are going to really help the patient participate in their care and make the lifestyle changes that ultimately are the root cause of the vast majority of these chronic illnesses, right? So I’ve been doing that for a long time, and mainly where I’ve been doing that is in the cash-pay realm, with direct primary care and models that have allowed doctors to sort of exit the system.

In the last few years, I’ve just become really passionate about solving the system itself, right? To actually change the system itself, rather than playing on the edges with cash medicine, which is never really going to get to the people who need it the most. Medicare, Medicaid, commercial insurance: Those are the people we need to get to. So that’s been tricky, because one of the things that’s really held back that evolution, a huge friction point, has been the coding changes. Look, if you have to see people in a five-minute visit, and then you don’t see them again for three months, it’s very difficult to enact that kind of empowerment onto the patient in that structure.

So when the 2021 coding changes came around, it was the most significant change in coding in history, in 30 years anyway. And there were some of those coding changes that I saw where I thought, “Hang on a minute.” If you were really paying attention and you were running your practice and really thinking through your product and service mix, there were some opportunities to actually start to really reorganize your practice around the idea of reversing chronic illness. So over the two articles that I wrote recently at KevinMD, I tried to share with doctors what those openings were and how they could take advantage of them to build models that not only would help empower patients toward better health but would also be helpful for the bottom line of these practices.

Kevin Pho: So let’s go into a little more detail. What would you say are the top coding changes? And then you could follow that with: What are some of the opportunities that these specific coding changes would bring?

James Maskell: Yeah, so some of the big coding changes: One is when you’re dealing with complex chronic illness, a lot of times doctors wouldn’t get paid for the effort that they would put in to really understand the case before the patient walked in, and then the case organization and collaboration after they left. So there’s time-based coding, and being able to count time that wasn’t necessarily patient-facing but was maybe other members of your staff. That is a significant shift, right? The more complex the illness that you’re dealing with, the more time it takes to really understand the root cause. So that was a significant shift.

There were significant shifts around how to use health coaches in the practice. Chronic care management codes were established, and then actually in 2022 the reimbursement of those codes for doctor-prescribed coaching was a big deal. And there’s this sort of pot of gold at the end of the rainbow for doctors, which is remote patient monitoring. I think all doctors love the idea of just understanding where their patients are, having a lot more dynamic data about where their health is trending, and catching things early. But the operational lift to execute any of those things is tricky. Getting remote patient monitoring up in your practice can be tricky. But I think there are sort of openings in some of those areas, where you say, “OK, I can at least envision that if we had some way of understanding where their health was happening in real time, if we had someone running that who was at a lower cost and could get reimbursed for monitoring that and then helping patients improve on those numbers, that would be really valuable.”

But the one area where I think there’s the most opportunity right now in medicine is around group medicine. I’ve been passionate about group medicine, and I actually wrote my second book, The Community Cure, on group medicine, because there’s so much synergy that happens when you put patients of like diagnoses together and take them through a combination of learning, accountability, mentorship, and support. I mean, that’s how they do it in Alcoholics Anonymous, right? That’s how we reverse alcoholism: We give them mentorship, support, and accountability.

One of the things that I worked out early on, after these coding changes, was that there’s a real opportunity for essentially virtual lifestyle medicine groups inside medicine today. And that’s what I’ve been working on with physicians: to make it really easy to implement those kinds of groups. They’re profitable, they’re effective, and for chronic conditions where lifestyle is a component, a six-month episode of care where groups of patients come together to start to implement healthy behaviors, all supported by health coaches, is a new opportunity for doctors that care about chronic disease reversal.

Kevin Pho: So give us a story or a case study of exactly how that would work. So let’s say I am a primary care physician, but let’s say I owned a small practice and I wanted to institute this group coaching model that you’re describing. Tell me a story of exactly what that would look like, and how would that be billed and coded for?

James Maskell: Yeah, so I’ll give you an example actually just right down the road here, because it was the first clinic that we worked with. So yeah, a primary care clinic, one MD, three PAs, all trained in lifestyle and functional medicine, but again doing very one-on-one appointments and finding it difficult to help people actually make the behavior changes. They can come up with a great protocol, but what percentage of people are actually executing that in the field? And because of the pandemic, and just because of the state of American life, Kevin, I mean, most patients are overwhelmed with life generally.

So I went to that doctor and I said, “Look, what if we could come up with a partnership where you do what you’re good at? You have the doctors, you have the insurance contracts, you have the patient base, and we’ll deliver all aspects of the group.” So ultimately, we’ll take care of not just hiring the coaches, training the coaches, delivering the curriculum, and running the technology, but also the annoying, boring parts that get in the way of running groups, like customer service, tech support, and those kinds of things.

So we ran a pilot. They recruited 65 of their patients. We put them in four groups of about 16, and over the next three months we took them through a curriculum that was based in Zoom. There was an opportunity for them to communicate in a sort of HIPAA-compliant Facebook-like group in between the sessions. We started to see some people are very good at making friends very quickly, and there was a huge loneliness factor out there, which is really a big driver of all chronic illness, too. But slowly you start to see these relationships being created. You start to see people getting it. They calm down, the nervous system calms down, and they’re feeling better. Some of the early signals that we saw were anxiety falling away, because people now had a safe space where they could talk about what it’s like to have a chronic illness, and they saw that the coach had had a chronic illness and reversed their own chronic illness, and they could speak to the other people in the group.

And then for the second half of the group, you really start to see real friendships emerging and real new behaviors emerging. At the end of that three-month episode of care, the outcomes that we were measuring on PROMIS were that more than two-thirds of the people who had high anxiety reduced anxiety, depression, fatigue, and pain. It was a full-spectrum biopsychosocial intervention, right? You have the social aspect, and they’re creating new friends. There’s a psychological aspect, because they’re learning to meditate, they’re learning to do box breathing, they learn to take care of their stress and think about their disease in a new way, and they’re really shifting from victim to hero of their own journey. And then obviously there are biological pieces, too, because we’re changing their diet and taking out some of the inflammatory foods, and people are supporting them to do it.

So a three-month biopsychosocial intervention led to significant improvements in these patient-reported outcome measures. Those were cross-validated in many of those cases with lab data that the clinic was doing, and that was the beginning of this journey to think, “OK, well, if this could work with one.” In the last year we’ve seen rheumatologists, pain doctors, gastroenterologists, any doctor that knows that the conditions that they’re seeing are being either created or exacerbated by lifestyle, come along, and we’ve had a fun time executing those same kinds of groups in partnership.

And the cool thing about what’s possible now, Kevin, is that because of the telemedicine changes, the patient doesn’t even necessarily know that this is like another company. It’s really viewed as an extension of the care of the clinician, and that’s helping to maintain a relationship with the clinic and to make the care profitable for the clinic.

Kevin Pho: And in terms of billing, is group coaching, like the scenario you described, accepted and able to be billed by most private insurers in addition to Medicare?

James Maskell: Well, the secret is that group care coaching is. But the way that we’ve organized the groups, and this took a little bit of finagling with the rules, actually mirrors what the AFP was recommending for group visits pre-COVID, which is essentially not to bill it as group coaching, but to bill it as individual visits. The way that we have it set up is that the provider sits in the Zoom breakout room and takes patients one by one into the Zoom breakout room to fulfill the criteria for what we call medical decision-making.

And that was actually one of the big changes in the coding. Forever, you would have to determine whether it was a 212, 213, 214, or 215 by severity or by how much face-to-face time you would have with the patients. One of the big shifts was medical decision-making. So if you can get into it with patients in the breakout room, talk about their medication, and talk about how their disease is either progressing or regressing or, ideally, reversing, then the coach can just be in the main room of the Zoom, and the provider can be in the breakout room.

That’s just some of the innovation that we’ve created in the last year to try and think about how to use these very familiar digital tools in a way that could really make it easy for doctors to do this and to take the operational risk off their shoulders. I mean, if there’s one thing I’ve learned in 17 years, it’s that doctors just want to do the basics of seeing patients, and they really want to help. A lot of times, if new ideas come with a lot of operational risk, they don’t get executed, or they don’t get executed well, and that’s not good for the patient, and it’s not good for the clinic. So we’ve looked to take as much of that off the shoulders of the clinicians as we can, so they can just focus on doing what they’re best at.

Kevin Pho: We’re talking to James Maskell. He’s a health care executive, and he wrote the KevinMD article “Get familiar with the 2021/2022 coding changes.” James, in addition to the group coaching model that you describe, what are some other low-hanging fruit that physician practices can take advantage of based on these recent coding changes?

James Maskell: Yeah, look, I think the chronic care management codes in 2022 went up by over 50 percent, while E/M visits went down. So I think, what does that tell you? Someone somewhere is looking at all this and saying, “Wow, these people who are billing these codes are getting increases in health in their community, and their outcomes are better, so let’s reward that.” So ultimately, if you look at codes like 99439 and 99490, the amount that they’re paid has gone up for 2022, but ultimately this is doctor-prescribed coaching again.

So I think if you look all across the board, coaching is coming into medicine, and we’re looking at ways to do that. And not only is that code payable, but certainly remote patient monitoring is best done by a coach as well. So I think the big news is it’s now profitable to deliver coaching inside your practice. Most patients with a lifestyle-driven chronic illness need some form of coaching to nudge behaviors in a more healthy direction. One-on-one coaching is cool; group coaching is much cooler. I think that’s a trend for 2022, and probably for the future, because if someone on high at CMS is seeing that and making those changes to the code, they obviously see, “OK, this is a behavior that we want to nudge forward in physicians and practices.”

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

James Maskell: For a physician entrepreneur, this is a very exciting time to be alive. COVID has shown us that we do a horrible job of creating resilient humans, and coding changes are shifting to be able to make that a reality for your practice. Ultimately, there are people like myself out there that are trying to make it as easy as possible for physicians, physician entrepreneurs, and even health systems to take advantage of this and take us toward a more sustainable, healthful health system.

Kevin Pho: James, thank you so much for sharing your time and insight, and thanks again for being on the show.

James Maskell: All right, thanks, Kevin.

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