Jeffrey Bendix is the senior editor of Medical Economics.

Jeffrey Bendix

Between 2011 and 2015 the government spent upwards of $35 billion subsidizing doctors’ purchases of electronic health records (EHRs) through the Meaningful Use program. It did so mainly in the expectation that EHRs would enable doctors to provide better care for patients and streamline practice and hospital workflows.

But the 2009 Health Information Technology for Clinical Health (HITECH) Act — the law that spawned Meaningful Use — included an additional motive for encouraging EHR use: advancing public and population health. The hope was that digitizing millions of patient health records would produce a treasure-trove of data that researchers could mine for purposes such as spotting disease outbreaks and developing new ways of treating chronic conditions.

Seven years after Meaningful Use, and three years into the COVID-19 public health crisis that has claimed more than a million lives, it’s evident that the hoped-for public/population health benefits of EHRs remain unfulfilled. That raises the questions, why haven’t those hopes been realized? Will they ever be? And were the public/population uses of EHRs oversold?

“We invested $35 billion and just went through a pandemic where we didn’t have enough information to answer the public’s questions about what we should do,” says Shannon West, chief innovation officer at the health information technology company Datavant and former chief technology officer at the Center for Medicare and Medicaid Innovation (CMMI). “And as taxpayers I think we should all be asking, ‘why isn’t this working?’”

And while government and the private sector are taking steps to address the challenges of making EHR data more easily accessible, most observers believe it will be years before those efforts come to fruition.

The challenges of using EHR data for public and population health purposes certainly do not stem from a lack of EHR use. According to government data, by 2019 90% of office-based physicians and more than 95% of hospitals were using EHRs.

Nor is the ability to send and receive data electronically — interoperability — the barrier it once was. And it is likely to become even less so thanks to the growing adoption of technologies such as Fast Healthcare Interoperability Resources, a standard used to access and exchange health care data, TEFCA — a “trusted exchange framework” for exchanging information between health information networks — and applied program interfaces, the architecture that enables development of apps for sending and receiving data.

The problems lie elsewhere, experts say, largely in incentives and policy choices built into the nation’s health care system. They begin with the challenge of prying patient health data from the institutions that own most of it — the large hospital systems and the practices they own, where most patients now receive care. These institutions are usually reluctant to share their EHR data due to fear it will put them at a disadvantage with competitors and/or payers, without being compensated for it.

“In health care nothing happens unless there’s money behind it,” West says. “At the end of the day if there’s not financial incentive to share medical records among providers or with public health departments the data is going to stay stagnant. It sounds so obvious but that’s the incentive you need for the behavior you want.”

That reluctance is understandable given the highly competitive nature of health care in many communities, says David Blumenthal, M.D., president of The Commonwealth Fund and former National Coordinator for Health Information Technology (ONC). “We don’t require or expect Toyota and BMW to exchange information. But in effect that’s what you’re doing when you ask two hospitals in the same community to exchange health data.”

Blumenthal adds that the lack of incentives for sharing data is part of a bigger problem, which is the priority the health care system gives to treating illness in individual patients versus preventing it among large populations.

“There is no business case for prevention in the U.S. health care system, which is primarily built on fee-for-service," he says. "But there is a very strong case for taking care of sick people. So you can’t expect technologies like EHRs to become solutions to health care problems when they are controlled by humans who will use then for business purposes. Lacking a business case for use of a technology it won’t be used to address that problem.”

The absence of a business case for sharing data was one of the motivations for adopting the 21st Century CURES Act and the Information Blocking Rule resulting from it, says Micky Tripathi, Ph.D., M.P.P., the current head of ONC.

“We recognize the business drivers of the health care system will be to not share information, Tripathi says. “But I would argue that health care has higher needs. That’s why with the Information Blocking Rule we’re telling them [doctors and health care organizations] they are compelled to share that information, or they will be penalized.”

Another barrier to using data EHR data for public and population health research is structural: the separation of health care for individuals--what most people think of as the health care system — from public health functions.

“It’s one of the historical challenges faced by health care providers and policymakers that we’ve kept public health and medical care separate in this country,” says Joshua Vest, Ph.D., M.P.H., director of the Center for Health Policy at Indiana University-Purdue University Indianapolis and a researcher at the Regenstrief Institute. “They are funded and governed separately. And so while integrating public health and health care would be beneficial in many ways there are also a lot of barriers to achieving it.”

Among the consequences of that separation is that public health functions are performed almost entirely at the state and local level. That fragmentation further complicates the process of finding and aggregating the data required for public and population health research.

“There are something like 64 public health jurisdictions around the country, each with its own rules around data collection and sharing,” Tripathi says. “Under those circumstances it’s really hard for the private sector, which controls most EHR data, to figure out all the regulatory issues involved with public health.”

Moreover, public health and the health care system face a vast imbalance in financial resources available. According to the 

, public health accounted for less than 2% of all U.S. health care spending in 2020. Similarly, a 2022 study by the Health Information Management and Systems Society concluded that the nation’s public health infrastructure needs a $36.7 billion investment over the next decade to address current and emerging threats to public health.

“Public health is chronically underfunded,” Vest says. So even if public health departments wanted to partner with health care organizations, they’re generally smaller and less technologically advanced.”

The consequences of that imbalance became painfully clear when COVID-19 struck. Ideally, says West, when a doctor treated someone with the disease that information would have been automatically transmitted to the local and state health department so the outbreak’s progress could be tracked and other doctors would have access to it. “That’s 100% not what happened, and still not happening,” she notes.

“We’d invested all this money in EHRs and created the ability to firehose a tremendous amount of health data,” Tripathi recalls. “But we didn’t make the corresponding investments on the public health side. And we found during the pandemic that when we turned those EHR firehoses on public health agencies they had no ability to receive that volume of data, let alone process it for the kind of response we needed.”

The lack of public health funding, and ability to aggregate data for research purposes has been filled somewhat by state health information exchanges (HIEs), networks that enable their members to search for and exchange patient data electronically. While some policymakers view HIEs as a possible way for researchers to access data for public and population health research, West is skeptical.

“One of the problems with HIEs is that some health systems don’t share all their data on individual patients or from every patient visit,” she says. “So you can build the connections (with HIEs) but the connections don’t necessarily all provide the same data. That’s where the idea starts to break down on a national level.”

Blumenthal agrees. “HIEs depend on people and institutions putting information into them to be effective,” he says. “That means their effectiveness depends on the community spirit of local health care organizations, along with the state regulatory framework that facilitates it.”

Despite the obstacles, some observers are optimistic that EHR data will be widely available for research purposes in the not-too-distant future. One is former CMS administrator Seema Verma, who notes that with EHRs now in widespread use and rapid development of standards and technology for data transmission, “it’s just a matter of figuring out how to aggregate and deidentify the data, and making it easy for providers by having their EHR software system send it automatically. I don’t think any of that requires a massive investment.”

Tripathi says that the federal government’s involvement in developing data sharing protocols such as TEFCA will make aggregation and research easier. “It’s only with the federal government stepping in to say, ‘Hey public health agencies, let’s agree on some basic rules of the road and then you can exchange information with each other,’ ” he says.

Blumenthal points out that mining of EHR data is already happening, in the form of partnerships between large health systems and tech companies with the ability to store and analyze large quantities of data. “Every patient encounter in that system end up in the company’s data warehouse where it’s deidentified and the company tries to make money from the resulting information.”

Partnering with the private sector provides the business care for mining EHR data, Blumenthal says. The drawback is the companies doing the research, such as Google and Apple, “are poring over those data looking for what they can make money from, not for ways to help the U.S. improve its health. They might hope that will be a side effect, but it’s not an altruistic activity.”

Regenstrief’s Vest finds grounds for optimism in the development of what he calls the “building blocks” of a comprehensive research network. He points to the many states with all-claims databases that are accessible for research purposes, and the National Patient-Centered Clinical Research Network which, according to its 

, provides access to data from more than 30 million patient encounters annually for a variety of research purposes, including population health.

The COVID-19 pandemic might also play a role in furthering the EHR-population health connection, Vest says, by driving development of large-scale patient registries among multiple academic institutions for research into the disease. These examples, Vest says, “demonstrate we have the knowledge and experience to do this sort of (public and population health) research using data drawn from multiple sources. Hopefully one day we’ll be in a position to scale them up and build something larger.”

Articles

Digitizing patient health data was supposed to make it usable for public and population health research. So far, that hasn’t happened.

The broken promise of digitizing patient data

Confidence in the public health system has eroded since the start of the 

, and public health officials themselves are partially responsible, according to a group of experts in the field.

“There are a lot of unforced errors that we in public health made [during the pandemic,]“ said Leana Wen, MD, former commissioner of 

 and a professor of health policy and management at George Washington University. “And I think it’s easy to point our fingers at, quote, the other side, like social media and politicians spreading misinformation, but we also need to take a hard look at what we in public healthmight have done better.”

Wen’s remarks came during a panel discussion, “The Broken Trust Between Public and Health” at the 2022 HLTH conference in Las Vegas.

Looking back, Wen said, public health officials could have better explained how evolving understanding of COVID caused changes in recommendations for countering the disease.

“If there’s anything I wish we had done differently, it’s emphasizing that change is the bedrock of good 

 policy. If the science changes, if circumstances change, you would expect that the recommendations also change. And I think that could have been communicated more forcefully,” she said,

Ezekiel J. Emanuel, MD, PhD, professor and vice president for global initiatives at the University of Pennsylvania’s Perelman School of Medicine and a venture partner at Oak HC/FT, cited changing CDC and World Health Organization recommendations on slowing the aerosol spread of COVID. “If you get something wrong that is so fundamental, and you’re resistant to changing it, I think it undermines public trust,” he said.

In addition, officials didn’t always consider the impact that decisions made in the interest of public health had on peoples’ lives. “A lot of the public felt during the pandemic as if the government wasn’t taking their situation into account,” Emanuel said, citing the example of school closings. “People had a sense like, ‘those government officials did not understand how this one action really turns my life upside down. That attitude really does undermine people’s confidence.”

Emanuel added that eroding public confidence in public health is occurring in the context of other trends, including a decline in trust of expertise that has been fanned by Republicans, and the ability of social media to spread false information. “Loss of trust iswider than just in public health,” he said.

Panelist Amy Abernethy, MD, PhD, president of clinical studies platforms at Verily, noted the impact of the public being able to view, for the first time, FDA advisory committee debates regarding COVID vaccines and boosters.

“The public saw the messiness of interpreting the data with micro-evaluations of safety events, and what did that really mean for populations and scale,” she said. “In the past we’ve shielded the public from that messiness, and now in a place where we’re trying to help the public understand and interpret the messiness in real time.”

Emanuel said the current divisiveness of the nation’s politics contributes to the undermining of public trust because “a lot of people think it’s to their political advantage to attack the experts.” Those attacks have led to the departures of many experienced public health officials leaving, which has been detrimental to the long-term good of the country, he said.

Wen said she is concerned that the backlash against COVID-mandated health restrictions has bled over into other areas of public health, citing the laws many states have enacted restricting the authority of local and state public health officials. “I hate the fact that public health has been politicized and polarized because of COVID,” she said.

Restoring trust in public health, Abernethy said, will depend on improving 

 between health officials and the public.

“We have to help people understand the information in front of them in ways that are easily accessible. Making sure we incorporate into our work experts in many different types of communications. And we’ve got to keep doing the science and getting that right.”

Panelists say lack of clear explanations for public health policy decisions adds to problem.

HLTH 2022: Trust in public health shaken by COVID-19 response

Despite its challenges, value-based care has shown great promise in improving health outcomes and access to care, particularly among traditionally underserved or high-risk patient populations.

That was the view of participants in the panel discission, “The Risky Business of Value-Based Care" at the 2022 HLTH conference in Las Vegas. Panel moderator Sara Pinto, a partner in the venture investment firm Emerson Collective, began by pointing out that currently only about 20% of Medicare reimbursements are value-based. But given the flaws in fee-for-service medicine, “in a lot of ways we need value-based care to work, and we all hope it will.”

Panelist Corbin Petro, co-founder and CEO of Eleanor Health, a company that provides mental health and substance abuse services, said that 90% of the population they serve are not connected to primary care. “We know we can engage with this population and improve the health, but we can only do it by taking on financial risk,” she said. “I think that’s the promise of value-based care, especially for populations that the health care system traditionally has left behind.”

Her view was echoed by Ali Khan, MD, MPP, chief medical officer for Chicago-based Oak Street Health, a network of primary care providers. “To me, the importance of value-based care is its ability to provide primary care where it didn’t exist,” he says, noting that Oak Street is the only health system to serve Chicago’s largely impoverished west side.

The same was true for many of the communities served by Khan’s previous employer, Iora Health. “These are places the medical-industrial complex has largely failed,” Khan said. “So if nothing else, value-based care has incentivized companies like ours to go into places that otherwise haven’t been touched by the health care system.”

Aaron Friedkin, MD, chief business officer for Homeward, a provider of health caree services to people in rural areas, says that by enabling his company to take on risk for large patient populations, “we can make investments to expand access to care deploying technologies and care models that may not be reimbursed under fee-for-service but that allow us to overcome many of the structural barriers to care found in many rural areas.”

Panelists also stressed that without the time constraints of fee-for-service medicine, their providers can take the time to get to know patients and build the trusting relationships necessary to provide high-quality care.

“You have to understand what’s top of mind for a community, and that’s not always health care,” Friedkin noted. “It could be ‘how do I pay my bills’ or ‘how do I get where I need to go?’ Knowing those kinds of things requires understanding not just the health needs of a community but everything that’s going on in their lives. If we show we can help with those issues is how we earn trust and the right to care for them.”

Panelists highlight care options unavailable under fee-for-service model.

HLTH 2022: Value-based care's potential

burnout cartoon_AdobeStock_231034133.jpeg

That is among the findings to emerge from a recent survey of physicians and health care administrators regarding levels of physician burnout, its causes, and physician satisfaction with their job and employer. The survey of 354 administrators and 66 employers was sponsored jointly by Jackson Physician Search and the Medical Group Management Association.

Asked if they are experiencing burnout—which the survey defined as “the long-term, cumulative 

 and depersonalization that doctors experience amid growing burdens in the practice of medicine—65% of the physicians “strongly” or “somewhat” agreed, up from 61% in 2021. Asked if doctors at their institution were burning out, 73% of administrators or managers strongly or somewhat agreed, compared with 68% last year.

When it comes to the reasons for burnout, however, the views of doctors and administrators diverged. Forty percent of doctors said their employer was either entirely to blame for their burnout or bore more of the blame than the general nature of a physician’s work. But only 19% of administrators or managers ascribed physician burnout to those two causes.

Regardless of the reasons for their feelings of burnout, a slight majority of respondents (51%) said they had considered leaving to work for a new health care employer during the past year, while 41% said they had thought about leaving medicine to work in a different field, and 36% had thought about 

. In a poll taken earlier in 2022 by MGMA and the website 

 40% of medical practices said they had a physician who resigned or retired early during the past year due to burnout.

 programs were another area of disagreement between doctors and administrators highlighted by the survey. When asked if their employer organization has a formal physician retention/engagement program, 8% of doctors said yes, 70% said no, and 22% weren’t sure. By contrast, 19% of administrators or managers said their organization had such a program, while 54% said theirs did not, and 27% weren’t sure. 

When it comes to reducing burnout, a 2021 MGMA Stat survey found it to be a low priority, with 86% of health care leaders reporting they had no formal plan or strategy for it. Programs that did exist were in the form of:

Investing in specialty-specific EHRs that are more intuitive and provide more functionality to help team members follow up on outstanding tasks;

Adopting formal physician wellness committees; and

Developing a one-on-one coaching/mentoring system

The survey concludes by noting that “awareness [of burnout] alone will not prevent physicians from exiting the profession in the coming years. It will require empathy and organizational efforts to restore professional relationships that make high-quality care delivery a sustainable reality, producing healthier outcomes and margins in the process.

 Despite prevalence, few institutions have formal programs for addressing burnout.

MGMA 2022: Burnout among doctors continuing to rise, survey finds

Health care policy experts and institutions have long agreed that fee-for-service (FFS) medicine is wasteful, outmoded and at least partially responsible for the U.S. spending far more than peer nations on health care, but with outcomes that are no better and often worse.

Now, after years of experimenting, cajoling, and incentives, value-based payment models — those tied to patient outcomes and spending targets — seem to be gaining traction. According to the Health Care Payment Learning & Action Network’s (LAN) annual measurement of participation in alternative payment models, slightly more than 60% of health care payments in 2020 included some form of quality and value component. That is up from 53% in 2017 and 11% in 2012.

Similarly, 49% of practices responding to the American Academy of Family Physicians (AAFP) 2022 value-based care survey said they are participating in some form of value-based payment, and 18% are developing the capabilities to do so.

That is welcome news to AAFP President Sterling N. Ransone, Jr., M.D., FAAFP. “Our system is set up to prioritize and reimburse based on volume of patient visits versus outcomes,” Ransone says. “Value-based care prioritizes outcomes. And however we can get our population healthier is where the health care expenditure should go instead of the transactional fee-for-service environment we’ve been in for so long.”


Much of the energy behind the search for alternatives to FFS comes from the federal government through the Medicare Shared Savings Program and the Centers for Medicare & Medicaid Innovation Center (CMMI). The latter — established in 2010 as part of the Affordable Care Act, former President Barack Obama’s health care law — is tasked with developing and testing payment models aimed at improving care quality for Medicare and Medicaid beneficiaries while slowing cost growth in both programs.

The COVID-19 pandemic has also changed some practices’ thinking about the importance of participating in value-based payment programs, says Corinne Lewis, M.S.W., program officer for delivery system reform at The Commonwealth Fund.

“Fee-for-service is a volume-driven payment system, so when patient volumes dropped (in the early phase of the pandemic), especially for elective and primary care, payments decreased substantially.” Lewis says. “So, providers are recognizing the need tomove toward more value-based approaches for more flexibility and protection against future volume shocks.”

In recent years the search for workable alternatives to FFS has been fueled by growing recognition of the role that factors such as access to adequate housing and nutritious food — social determinants of health — play in determining patient outcomes.

“How can we address patients’ behavioral and social needs in order to meaningfully bend the health care cost curve?” Lewis asks. “There’s growing recognition that value-based care will be essential to all those things and that’s where a lot of the interest is coming from at the Medicare/Medicaid level as well as commercial payers and providers themselves.”

Do these developments mean value-based payment models are the wave of the future, and FFS medicine will disappear? Probably not, experts say. There are still numerous obstacles to increasing provider participation in value-based models, and powerful forces working to preserve FFS.

Among the obstacles is the term “value-based care,” says Suzanne Delbanco, Ph.D., Catalyst for Payment Reform’s executive director. “It implies that whatever care is provided is of good value, which isn’t always the case,” Delbanco notes. Instead, she says, we should think in terms of payment reform and care delivery reform, with the latter being defined as “approaching care more broadly than just one visit at a time.”

“Both are needed for either to succeed,” Delbanco argues. “Payment reform for its own sake isn’t exciting, but if it can lead to higher quality, more affordable care it becomes interesting. And new care delivery models aren’t likely to be sustainable unless there’s a way of paying for them that makes them attractive to providers and leads to better results.”

Judged by those standards, movement away from FFS is less impressive than it first appears. Although LAN’s data show 60% of 2020 health care spending was in some form of alternative payment models, most of that was in programs built on FFS but including opportunities for additional revenue such as care coordination fees or through shared-savings programs. Only 6% of total spending was population based, such as per-member per-month or global budgets, and not linked to FFS.

‘Incentives haven’t really changed’

“Fee-for-service is still at the base of most alternative payment models,” says Delbanco. “The doctor or hospital is still billing and getting paid that way. So, for the front-line physician the day-to-day incentives haven’t really changed.”

Little of this comes as a surprise to Robert Berenson, M.D., a fellow at the Urban Institute’s Health Policy Center and former vice chair of the Medicare Payment Advisory Commission. “In my view, the people who come up with value-based plans don’t really understand the strengths and weaknesses of the various models, so they just focus on what they think are elegant new incentives without realizing some of them can’t be implemented.”

He cites the example of Medicare’s implementation of a payment code for “check-in” telephone calls with patients before an office visit, under the premise that such calls might head off unnecessary visits and save the program money.

The problem, Berenson says, is that the code’s payment amount—$14.53—was less than what it cost practices to bill for the service when administrative costs were factored in. “Docs aren’t completely stupid. They aren’t going to work below costs,” he said. “It’s an example of what sounds like a good idea in theory but operationally it makes no sense.”

Another hurdle many practices—especially small ones—face with value-based payment contracts is the upfront cost of the technology and personnel they need to compile, analyze and report data showing they have met a payer’s quality metrics. Such is the case for Melissa Lucarelli, M.D., FAAFP, owner of a family practice in rural Randolph, Wisconsin, and member of the 

“Our margins are so thin right now that it’s hard for me to pay upfront to jump on board a payer’s (value-based) initiative that will increase my administrative burden and may or may not increase my revenues,” Lucarelli says.

Nearly all Lucarelli’s Medicare patients are in some form of FFS-based quality program that includes bonuses for meeting certain Healthcare Effectiveness Data and Information Set quality guidelines, she says. Whenever possible, she bills for services such as chronic care and transition care management, advance care planning and cognitive impairment assessments.

“These piecemeal things are how we’re staying afloat right now,” she says. “But the administrative burden even from these on my little independent practice is phenomenal. It’s like being in a game where they change the rules every year.”

Making the challenge even greater is the sheer number of value-based arrangements. In addition to those available through Medicare and Medicaid, virtually every commercial payer has them, each with its own reporting requirements and quality metrics. For practices in contracts with multiple payers, keeping track of it all can seem like an insurmountable hurdle.

“A lot of our members, especially in small and solo practices, say they don’t have the resources to make sure they’re following the participation requirements (for alternative payment models), or even find out what they all are,” says AAFP’s Ransone. “So, they just throw up their hands and say, ‘Forget it, I’m not even going to bother.’ ”

Ransone adds that the academy has a project underway to address the problem. Dubbed “Vision 2025,” its goal is to reduce variability in payment structure and participation requirements for value-based models so small practices can receive the enhanced payments they often provide.

CMMI, in its 2021 “Innovation Center Strategy Refresh” white paper, acknowledged these and other problems with the value-based care models it has developed and experimented with for Medicare and Medicaid. Among the challenges it cites are complexity and overlap among many of the models; difficulty for providers to join or stay in value-based plans due to administrative burden and upfront investments; and developing better coordination among stakeholders.

“Alignment with private payers, purchasers and states is needed to increase the number of providers participating in value-based payment models and to make their participation sustainable across payers,” the paper says. To accomplish this, CMMI promises more public outreach in the form of listening sessions with payers, providers and health care purchasers, as well as learning from nonparticipants about barriers they face to participating in value-based models.

The paper notes that although CMMI has launched more than 50 models during the past 10 years, only four have met its requirements for being continued and expanded. “I think a lesson from the last decade that CMMI has taken to heart is the need to focus on a smaller number of strategic models that can really move the system,” says Mark McClellan, M.D., Ph.D., professor of medicine and business at the Margolis Center for Health Policy at Duke University and a former CMSadministrator.

Another obstacle to widespread use of value-based care and payment models, experts say, is the number — and power — of individuals and institutions who are satisfied with the current system. “There are many stakeholders who are fat and happy with the status quo,” says Catalyst for Payment Reform’s Delbanco. “Too many providers, and even payers, have found ways to be profitable with payment systems and delivery models that aren’t linked to quality.”

Berenson notes that more widespread use of payment models such as capitation or bundled payments would benefit primary care physicians more than specialists, because many services the former perform are underpaid or not billable. “Many of them (specialists) earn more than twice as much as primary care doctors, and they have enough power to prevent CMS from changing that on its own or from Congress authorizing CMS to do it,” he says.

What lies ahead for value-based care and the payment models that support it? Experts believe participation will continue to grow, but that FFS is not going away — in part because it remains well suited to some forms of care. “I don’t think fee-for-service will ever be eliminated entirely, because in some cases it can be an appropriate mechanism for incentivizing care that we want to see more of,” says Lewis.

Berenson agrees, citing vaccinations as an example. Practices need to be reimbursed for purchasing the vaccines, which is next to impossible under a capitation model given their year-to-year price variation. Beyond that, Berenson says, “if you pay fee-for-service for immunizations it’s much more likely they will be performed. And when you’re using fee-for-service to make sure an important service is provided, it means you’re improving value.”

FFS is also appropriate in primary care for discrete services such as hospital visits or minor surgeries, Berenson says. But in general, he adds, primary care clinicians would fare better under some form of value-based model such as capitation.

He cites research showing that up to 30% of activities primary care doctors perform, such as calls to pharmacies or patient callbacks, are not coded and so are not billable under FFS. “The beauty of capitation is, you don’t have to code for all those services. Instead, the payer says, ‘We’re going to pay youfor taking care of this population of patients and you allocate your time and resources to accomplish that,’” Berenson says.

Duke’s McClellan says the increase in telehealth visits resulting from the COVID-19 pandemic is another reason why primary care clinicians and their payers should favor alternatives to FFS. Under FFS, he says, there is little incentive to use telehealth for the patients who would benefit the most — such as those in rural areas — and to coordinate telehealth with other community-based services those patients often need to address their health issues.

“You rarely see significant programs to address the social (determinants) of poor health in an FFS model because there just isn’t any way to do that,” he says. “How are you going to pay for air conditioners or transportation or whatever else the patient needs? Community-based health services are easier to provide widely in value-based arrangements because they’re built on the foundation of accountability for total costs and outcomes for patients.”

Ultimately, experts say, what’s needed are payment models that combine elements of FFS and value-based arrangements. For Lucarelli, such a hybrid approach would include “some form of per-patient reimbursement, or income floor, that covers stuff like doing their prior (authorizations) and coordinating with specialists.” Such an arrangement, she explains, “would allow us to provide these services regardless of the ebb and flow of patient volume during the year.”

Specific procedures, such as minor surgeries or IUD implants, should remain under FFS, she adds. “That way I’m fully reimbursed and can practice to my full scope of training. If I’m just getting a capitated amount, then doing most procedures becomes money out of my pocket and I might as well send the patient to a specialist.”

Outcomes-based models are spreading, but fee-for-service still dominates payment landscape.

Value-based care catching up to fee-for-service

 to evaluation and management (E/M) billing guidelines that allow physicians to bill for previously unreimbursed services are producing higher revenues for longer patient visits, according to results of a new study.

 looks at the financial impact of CMS’s 2021 expansion of its time-based billing guidelines to include time spent on previously unreimbursed tasks associated with patient visits, such as medical record review and 

CMS’s goal, according to the authors, was to give doctors an opportunity to increase revenue compared with 

based billing, wherein reimbursement generally increases with the number and complexity of problems addressed during the visit.

To compare revenues under MDM versus time-based billing, the authors developed a model for an individual physician seeing patients eight hours per day for 220 days a year. The model included both new and returning outpatient visits with Current Procedural Terminology codes 99202 to 99215, which are the ones doctors can use for time-based billing. They also assumed doctors scheduled twice as much time for a new patient visit as for returning patients.

They found that the shortest MDM-based visits —20-30 minutes for new patients and 10-15 minutes for returning patients—resulted in annual revenue of $846,273, compared with $567,649 for the shortest time-based visits of 20 minutes for new patients and 10 minutes for return visits. E/M revenue in the time-based revenue stayed fairly steady, regardless of the time length of the visit.

The revenue advantage reversed with longer visits, however. Beginning at 40-minute new patient and 20-minute returning patient visits, time-based billing was associated with $458,718 versus $423,137 for MDM-billed visits.

Overall, the researchers found that the highest E/M revenues were associated with a combination of short patient visits and MDM-based billing. On the other hand, they say, the model demonstrates that doctors with longer patient visits can benefit from time-based billing.

Moreover, because E/M revenue wasn’t associated with visit length, doctors with longer patient visits could extend them even further without a noticeable loss of revenue. And since time constraints have been shown to decrease the likelihood of doctors completing preventive medicine tasks, “the flexibility in patient scheduling afforded by time-based billing could help physicians better address preventive medicine.”

The study, “Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits,” was published August 31 on 

Time-based visits gain financial advantage over medical decision-making in some circumstances.