Provider Insider

Issue 6

Table of Contents

Leadership Message

A message from Dr. Austin Bailey


This year, Coordinated Care joined more than 650 ACO stakeholders at the spring 2019 NAACOS conference in Baltimore, MD. With presentations from both ACO leaders and CMS officials, and exhibitors showcasing the newest technologies and cutting-edge methodologies in health care, the event added an exclamation point to the perpetually changing health care climate.


Our participation in this event placed Coordinated Care at the forefront of our industry with the ability to bring back to our community news, information and best practices in population health management from across the country.


Operationalizing those ideas takes strong leadership and hard work which is why I’m pleased to introduce to you Elisa Wetherbee. Lisa joined the network’s administrative team last month as UCHealth vice president of population health and CIN executive with the express purpose of improving the CIN’s performance in the value-based contracts we hold.


“This is the right time in the health care environment to focus on value-based care for a health system,” Wetherbee said.


Ms. Wetherbee has worked in the Denver health care market for over 25 years and has experience in large group practice management, hospital administration, value-based contract administration and physician contracting. She has held executive positions at HCA, Exempla/SCL and Physician Health Partners.


“Building high-performing teams that bring value to medical practices is my passion,” Wetherbee said. “I’m just ready to get started.”


Please join me in welcoming Lisa to the team. And as always, we encourage you to bring any questions, comments or ideas to our network engagement team so that, together, we can continue our great work in population health management and find even greater success in our value-based contracts.


Austin Bailey, MD

Medical Director, Network Engagement for Population Health

Care Management

Transitional care management and reimbursement opportunities


CMS requirements


The 30-day TCM period begins on a person’s inpatient discharge date and continues for the next 29 days. Patients qualify for TCM services when they are discharged from one of the following settings:

  • Inpatient acute care.
  • Hospital outpatient observation or partial hospitalization.
  • Skilled nursing facility.
  • Inpatient rehabilitation facility.
  • Long-term care hospital.
  • Inpatient psychiatric hospital.
  • Partial hospitalization at a community mental health center.


The following health care professionals may furnish TCM services:

  • Physicians (any specialty)
  • Nurse practitioners
  • Physician assistants
  • Certified nurse-midwives
  • Clinical nurse specialists


Required components for TCM:

  • Interactive contact with the patient or caregiver within two business days after discharge via phone, email or in person, or two or more unsuccessful separate attempts in a timely manner.
  • Non-face-to-face services:
    • Review of discharge summary or continuity of care documents.
    • Review need for, or follow up on, pending diagnostic tests and treatments.
    • Interact with other health care professionals who will assume or reassume care of patient’s system-specific needs.
    • Provide education to patient and family/caregiver.
    • Establish or reestablish referrals and arrange for needed community services.
    • Assist in scheduling required follow-up with community providers and services.
    • Communicate with agencies and community services that the patient uses.
    • Provide education to the beneficiary, family, guardian and/or caretaker to support self-management, independent living and activities of daily living.
    • Assess and support treatment adherence and medication management.
    • Identify available community and health resources.
    • Assist the beneficiary and family in accessing needed care and services.
  • Face-to-face visit.
  • Medication reconciliation and management must take place no later than date of face-to-face visit.
  • Documentation of medical decision making (moderate or high).




CPT codes:



***Level of medical decision making and then time frame for face-to-face visit determines which CPT code to use. For example, if patient is moderate complexity decision making and seen within seven days of discharge, the CPT code 99495 must be used.


***Aetna, Anthem, Cigna, Humana and Kaiser reimburse for TCM services and follow CMS requirements.



Next steps


The CIN is currently developing tools to help support the TCM services; look for this in the next newsletter.


Please contact [email protected] with any questions.

Practice Spotlight

Matthews-Vu Medical Group: best in class


A quiet, competitive spirit drives the team at Matthews-Vu Medical Group; a desire to be the best at what they do. “Practicing good medicine” is more than something they say, it’s something they do. And they challenge themselves to do more and to be better every day.


Three years ago, this determination manifested in a collective commitment to population health. Today, Matthews-Vu Medical Group has improved quality measures across the board and consistently delivers top performance in Coordinated Care’s value-based contracts.


“It’s amazing to see how far we’ve come. Dr. Vu has always been committed to delivering good health care. But now, everything we do is documented and trackable,” said Sara Sanderson, RN and population health manager. “We have made a big impact on 37,000 lives.”


Building a program


Like many organizations, Matthews-Vu Medical Group started their journey with funding available through the Comprehensive Primary Care Plus (CPC+) program. They recruited Sanderson to build their program, design a process for case management and develop a risk stratification model; they used trial and error to figure out the rest.


“It has been a transition. Practicing good medicine is sometimes hard,” said Paul Novotny, director of operations. “Checking boxes and coding can be tedious. It’s not for everyone. But this is the way we do it.”


Matthews-Vu Medical Group now has ten, dedicated population health team members. They work as an efficient unit preparing for patient visits with a “needs checklist” prior to each appointment, making inpatient calls, contacting frequent ED utilizers and leading care teams to make sure no patient is left behind. But those team members will be the first to acknowledge that, to be successful, it takes a village.


“It’s a team effort. Our providers understand that good patient care takes time and it’s imperative they rely on the members of their team to help them accomplish the many goals we have. The work begins long before the patient ever schedules their wellness visit,” Sanderson said.


And patients are not exempt from responsibility in managing their own health care. The staff has worked hard to educate patients about the importance of wellness visits, and trained them to expect reminders for annual exams and quarterly diabetes checks.


“Even our high-acuity patients know they are accountable for fulfilling the care plan we prescribe,” Sanderson said. “We’re going to give them the best care possible, but the rest is up to them. We want to help patients independently manage their own health care, not become dependent on the system.”


Finding long-term success


With population health management, there is always something more to do. To find success early on, you have to be willing to let things go. Start by evaluating programs for common measures and financial benefits. Determine how many patients are affected by each measure, and implement across all patients, not by payer.


“There are always going to be patients who go to the emergency room unnecessarily. If it’s once for a cough or sinus infection, you have to let it go. If you start to see a pattern of consistent misuse, then it might be time to give that patient a call,” Sanderson said.


Sanderson would know. Matthews-Vu Medical Group is one of Coordinated Care’s best in reducing the number of potentially avoidable ED visits. They also know a thing or two about scheduling wellness exams.


“It’s really hard to get patients between the ages of 18-30 in for a wellness exam. They’re indestructible… it’s just not going to happen,” Sanderson said. “Despite that, we’ve doubled our wellness visits in just two years. You focus where there is opportunity.”


And there’s always opportunity—especially in an office with an open-door policy.


“Matthews-Vu Medical Group is not closed to anyone at any time. We successfully accept unlimited Medicaid patients.  It’s not easy, but it’s not impossible,” Novotny said. “If you look at the data monthly or quarterly, it will make you crazy. But when you look at the results year-over-year, even every two years, you can really see the changes in the data. It makes it worth the extra effort.”

Pharmacy Integration Insights

Making the switch: the value of transitioning patients to generic medications




Branded medications frequently are prescribed for a variety of reasons: provider preference, direct-to-consumer advertising, therapeutic niche, mistake, etc. Sometimes branded agents have unique mechanisms of action and could be beneficial for patients, especially if they have not responded to other therapies; however, many of these products commonly have a generic alternative that is therapeutically equivalent, but much less expensive.


The importance of generic medications for patients and the health care system.


Generic medications not only save the health system valuable health care dollars, they often are much less expensive for patients. The FDA estimates that generic medications cost an average of 85% less than brand medications.1 Also, three times more patients have been shown to abandon or be non-adherent to their branded medications; this is likely due to high-cost copays. It is estimated that only 39% of branded medication copays are under $20. By comparison, 90% of generic medication copays are under $20. As such, switching patients from a brand name medication to a generic may improve adherence simply from a cost perspective.2


Within Coordinated Care, brand-to-generic interventions have the potential to directly impact our Quadruple Aim by:

  • Reducing costs.
  • Improving patient experience by decreasing copays and improving outcomes through improved adherence
  • Improving care team well-being by decreasing patient complaints related to the cost of medications.
  • Improving population health by addressing quality-based metrics of adherence and comprehensive medication review.

Interventions to identify patient candidates who may benefit from switching from brand to generic medications are underway within Coordinated Care.


Already, centralized clinical pharmacists are identifying patients currently taking specific high-cost medications (outlined in Appendix A) through custom, population health-generated reports. These patients are contacted and asked if they would like to switch to the generic equivalent of their medication. If so, a recommendation or new prescription is pended for their primary care provider’s review.


In addition, this clinical pharmacy team is performing prospective comprehensive medication reviews (CMRs) for patients with upcoming appointments with the intent of optimizing chronic condition management and ensuring accurate medication lists. Part of this process is identifying high-cost medications, assessing barriers to access of these medications (if any), and recommending less expensive, therapeutic alternatives (as applicable).


The following tables illustrate the potential cost savings from switching from a brand to a generic product in patients with COPD/asthma, and guidance on how to do so (switching from brand name ICS/LABA combination products to generic Wixela).





Key messages:

  • Switching/starting generic alternatives can have a large financial benefit for patients and the health system (Tables 1 and 2), as well as potential improved adherence to therapy.
  • Coordinated Care centralized clinical pharmacy team is actively identifying patients eligible for brand to generic medication switching. Potential medication opportunities are outlined in Appendix A.
  • One current initiative is to more frequently utilize generic fluticasone/salmeterol (Wixela) for patients with COPD/asthma. Providers can do so by choosing generic products when initiating ICS/LABA therapy or considering switching patients from current ICS/LABA combination product to Wixela (Table 3).


Questions or comments? Please contact [email protected].


Kyle Troksa, PharmD, PGY2 Ambulatory Care Resident, authored this article.




  1. Food and Drug Administration.
  2. Association for Accessible Medicines.
  3. 2019 UptoDate.


Appendix A: High-Cost Medications (not all-inclusive)

Common high-cost medications that could potentially be addressed:

  • Advair → change to Wixela (generic fluticasone/salmeterol).
  • Fortamet change to generic metformin.
  • Nascobal → assess need for B12 supplementation and change to PO, IM or SQ cyanocobalamin.
  • Bystolic → change to metoprolol or carvedilol.
  • Myrbetriq → assess previous anticholinergic medications, consider switch to tolterodine or other generic anticholinergic.
  • Januvia → assess current and previous antihyperglycemic medications, consider switch to cheaper and more effective medication or optimization of current regimen.
  • Janumet → assess current and previous antihyperglycemic medications, consider switch to cheaper and more effective medication or optimization of current regimen.
  • Cambia → change to generic diclofenac.
  • Vyvanse → assess previous stimulant trials, consider switching to other generic stimulant.
  • Toviaz → assess previous anticholinergic medications, consider switch to tolterodine or other generic anticholinergic.
  • Dymista → change to generic fluticasone monotherapy.

Network News

An update about what is happening within Coordinated Care:


• IT Update: Claims Data


If you have news or announcements to share with network colleagues, please send to [email protected] and include Provider Insider News in the subject line.




In late April, Coordinated Care sent a few team members to the National Association of ACOs’ (NAACOS) spring conference in Baltimore. Twice a year, NAACOS brings together more than 600 ACO clinical leaders and administrators to discuss strategies, case studies and lessons learned from leading ACOs nationwide. April’s conference covered topics such as:

  • Transitions of care programs
  • Telehealth
  • Post-acute care partnerships and strategies
  • New CMS/CMMI payment models (Primary Care First, Direct Contracting)
  • Regulatory updates
  • ACO compliance
  • ACO financial management

CMS Administrator Seema Verma also spoke at the event, hinting that new mandatory value-based models will be announced over the coming months. Administrator Verma also indicated CMS is reviewing old laws and regulation and evaluating how these hinder the shift to value-based care.


Please contact [email protected] for more information.


IT Update: Claims Data


Effective April 2019, clinical data derived from paid claims from Anthem was integrated into CU Trust patients’ clinical records in Epic. Data being brought in includes encounters, diagnoses, procedures, and immunizations. Medication dispense data will be brought in starting in July 2019. CU Trust patients include UCHealth, CU Medicine, and University of Colorado employees and dependents.


Paid claims data provides information on care provided outside of UCHealth’s instance of Epic. This data includes any paid claim for an attributed patient regardless of their place of service.