What is the business case for creating primary care teams?

In addition to serving the business of healthcare by improving the very core of our work — improving patients’ health — implementing Team-Based Care has the potential to:

  • IMPROVE staff satisfaction and retention
  • ENHANCE patient satisfaction and loyalty
  • POSITION clinics to capture pay-for-performance and quality improvement bonuses and grants
  • STREAMLINE workflow and maximize the use of staff
  • IMPROVE efficiency

The first step to ensuring a return on team-based care is to understand your organization’s unique financing structure. Examine your payer mix and learn what types of practice activities generate revenue. Consider:

  • If you are reimbursed primarily on a fee-for-service basis, you will generate more revenue by using your care team as a provider–extender, enabling more patients to see the provider for a billable visit each day
  • If your organization accepts full risk for patient costs, then ensuring that your patients are taught how best to manage their illness and avoid specialist or emergency room visits will likely provide a more robust financial return
  • If you’re paid a capitated fee for primary care services, experimenting with alternative visit types may maximize your ability to care for more patients

Because the business of healthcare is to deliver the highest quality care to patients, improving clinical performance is our driving focus. However, understanding and responding to the reality of financial pressures through increased efficiency and enhanced revenue capture is what makes clinical changes possible and sustainable.

Publications

  • Publications

    Business Case for Behavioral Health Integration

    Learn about the concept of a business case and a process to develop one, through the lens of making the case for integrating behavioral health into a primary care practice. This presentation by Roger Chaufournier highlights reimbursement considerations and resources to help you build your business case for behavioral health integration.

    Attribution:

WorkflowTemplates, flow sheets and mapping aids

ToolkitsImplementation guides and other documents with extensive resources included

LEAP Learning ModuleOther helpful topics included in this website

Case summariesVignettes, profiles and testimonial videos

Publications and presentationsLiterature and PowerPoints on team issues

FAQ

Question

We have implemented some parts of team-based care in our practice, but are limited by our fee-for-service payment structure. How can we pay for nurses and other team members to do more?

Answer

  • Most practices are paid FFS. Even additional pots of bonus money for quality or minimal PMPM payments for care coordination leave unchanged the fundamentals of FFS. This is a common issue. Caring for more patients with the same number of providers is a reality in a FFS setting.
  • Familiarize yourself with level-one evaluation and management office visit codes (E/M). For example, CPT code 99211 is an office or other outpatient visit that “may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing/supervising these services.”
  • New payer codes for Medicare preventive visits, transitions of care, and care coordination do not require a physician.

Question

Our patients are covered by all kinds of different payers, how do we create a coherent care team model in this kind of environment?

Answer

Primary care practices are faced with many different payers and many different and sometimes conflicting financial incentives. Excellent, demonstrable quality of care will go far in helping you make a financial case to your payers and healthcare partners (e.g., area hospitals). Keep in mind, too that revenues are only one side of the equation. Reducing costs benefits all practices, regardless of payer source.

Question

There is a lot of talk about risk sharing arrangements where primary care practices could benefit from managing patient health and utilization. (e.g., Accountable Care Organizations, cost sharing arrangements, value-based contracts, or pay for performance). Can team-based care help me financially in these new arrangements?

Answer

Yes. May have upside or both upside and downside risk. In any case utilization and quality are concerns. Evidence shows executing well on the functions described in this guide are likely to help.

Question

Can I bill for services provided by a certified diabetes educator or a licensed clinical social worker?

Answer

Billing for CDEs depends on the payer. Billing for behavioral health specialists, such as licensed clinical social workers, depends on the payer and the state.

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