Provider Insider

Issue 7

Table of Contents

Leadership Message

Increasing Our Shared Savings


A word from our medical director, Dr. Austin Bailey.


Hello everyone. It’s that time of year when we learn about our collective performance in our value-based programs for the previous year, and whether we have achieved shared savings dollars to distribute to you. As we have been discussing in our monthly meetings at your practice, these shared savings pools have been diminishing in size over the past several years. Why? Cost!


To create a shared savings pool in a performance year, our trend for the population’s total cost of medical care—including pharmacy costs—must be lower than the cost trend for the payer’s Colorado market. Even though we succeeded in doing this in past years, it is getting harder to sustain that success.


Going forward, we will focus on several cost drivers that we believe we can most readily influence. This includes our continued focus on emergency department utilization. We will address pharmacy costs and implement some easy steps to help providers avoid unnecessary use of high-cost medications. We will focus more intensively on management of transitions of care from acute hospitalizations and emergency department visits. Continued analysis of the claims data will inevitably suggest other areas that we should address.


We will continue to support the excellent work that all of you are doing on quality metrics. Where shared savings pools have declined over time, your quality performance has continued to steadily improve. While this is most important for patients’ outcomes, higher quality scores also allow us to get more of any shared savings pool that we produce.


As always, overall success of the Network is dependent on the excellent work you do every day in your practices. We applaud your continued efforts toward improvement.

Clinical Programs

Transitional care management (TCM) FAQs.

Q: What current procedural terminology (CPT) codes do I use to report TCM?

A: There are two CPT codes that may be used:

    • 99495 Transitional Care Management Services with the following required elements:
      • Interactive contact via phone, email, or in person with patient and/or caregiver within two business days of discharge.
      • Medical decision making of at least moderate complexity.
      • Face-to-face visit within 14 calendar days of discharge.
    • 99496 Transitional Care Management Services with the following required elements:
      • Interactive contact via phone, email, or in person with the patient and/or caregiver within two business days of discharge.
      • Medical decision making of high complexity.
      • Face-to-face visit within seven calendar days of discharge.


Q: Why shouldn’t I just bill an office visit instead (e.g., CPT 99214)?

A: Code 99214 represents the second-highest level of care for established office patients with a reimbursement of $108 and a 1.5 RVU. Comparatively, CPT 99495 reimbursement is $168 and a 2.11 RVU, and CPT 99496 is $237 and a 3.05 RVU.


Q: What is required to document in the patient’s medical record?

A: At minimum, the following is required:

  • Date the patient was discharged.
  • Date of the interactive contact with patient or caregiver.
  • Date of the face-to-face visit.
  • Complexity of medical decision making (moderate or high).


For more information on medical decision making, please refer to this summary table:


Pharmacy Integration

Medication selection: Tools to minimize patient cost and make prescribing easier.


Medications are one of the highest costs of health care for both patients and payers, and represent a significant cost-savings opportunity in value-based arrangements. In 2016, over $329 billion was directly spent by patients and payers in the U.S. on outpatient medications.1 Drug cost varies widely for formulary-covered agents, and the exact cost is not readily available to prescribers. In general, utilization of generic drugs as preferred options drives cost down. For example, the Anthem EPHC value-based contract has a generic drug prescribing rate of 87%, yet the 13% of brand-name drugs prescribed represent 85% of the overall outpatient drug cost in the program. Further, it is estimated that a 1% increase in generic prescribing can result in a 2.5% to 3.5% reduction in overall drug cost. Increasing generic prescribing rate to 90%+ and utilizing less expensive brand-name options represents a significant cost-savings opportunity.


The challenge.

Selecting low-cost medications can be challenging for prescribers. The medication formularies have wide variation, cost is often negotiated and not transparent, and changes are frequent. It is common for a medication to be prescribed, the patient to find out at the pharmacy it is not covered, and for the prescriber to rework by sending an alternative prescription. This is frustrating for all, and results in higher cost.


Real-time benefit check tools at the point of prescribing continue to improve, but are not yet seamless, and are not yet comprehensive for all medication formularies. This technology will continue to improve, but a more immediate solution for value-based programs is needed.


A solution—Formulary Quick Reference Guide.

The population health pharmacy team has begun to develop Formulary Quick Reference Guides for common classes of medications such as antidiabetic medications, inhalers and statins. The goal of these references is to increase cost transparency to improve provider efficiency and decrease costs to patients and payers. By providing a snapshot of potential costs and the payer’s preferred medications prior to prescribing, there is a reduced back-and-forth between pharmacies and prescribers and a potential lower cost.


Sample from the Diabetes Formulary Quick Reference Guide:



Coordinated Care’s engagement team has begun to disseminate this tool to provider practices and the feedback has been positive. The pharmacy team will continue to develop additional classes of drugs, and will update existing documents routinely.


The following case study provides an example of how a provider and care team could use the tool to improve care and reduce cost.


Case study.

Dr. Brown is wishing to add a second diabetes medication to patient AB, a 52-year-old female with Type 2 diabetes without renal complications and a most-recent Hgb A1C of 7.5%. AB is currently only prescribed metformin and wishes to take a once-daily oral medication. Her fasting blood sugar is controlled, but her post prandial continues to stay slightly elevated. The patient denies any signs or symptoms of hypoglycemia. Both options below present acceptable prescribing options that will yield similar results, but have two very different costs to the patient and payer.

Option 1:

  • Metformin 1000 mg ER (Fortamet)—2 tablets, once daily
  • Sitagliptin (Januvia) 25 mg once daily—1 tablet, once daily

Total annual cost: >$15,000

Option 2:

  • Metformin 500 mg ER (generic Glucophage)—4 tablets, once daily
  • Glipizide 5 mg XL—1 tablet, once daily

Total annual cost: ~$1,000


Please contact Joseph Vande Griend with any questions.


Joseph Nardolillo, PharmD, PGY2 Ambulatory Care resident, authored this article.


  1. Micah Hartman et al.; “National Health Care Spending in 2016: Spending and Enrollment Growth Slow After Initial Coverage Expansions”; Health Affairs 37(1): 150-160; January 2018. Note that the “retail prescription drugs” category excludes drugs purchased directly from physicians or hospitals (e.g., infusion drugs).

Value-Based Contracts Issue 7

New payment models for primary care.


The Centers for Medicare and Medicaid Services Innovation Center (CMMI) recently announced two new voluntary primary care payment models: Primary Care First (PCF) and Direct Contracting. PCF is a program between your practice and CMMI (similar to CPC+). Direct Contracting is available for the Integrated Network, but is advanced beyond our current network capabilities. We want to make you aware of this value-based program in which you could participate individually, as Coordinated Care will not pursue the more advanced program at this time.


The new, five-year PCF model is designed for practices experienced with value-based payment arrangements that are ready to take on downside risk for Medicare fee-for-service patients in exchange for reduced administrative burden and performance-based payments. PCF has two payment types:

  • A risk-adjusted population-based payment (per-member-per-month).
  • A flat primary care visit fee.

Together, these payments make up the total primary care payment, which can be adjusted up to 50%, and a maximum downward adjustment of 10% dependent on performance.


CMMI announced two cohorts: non-CPC+ practices can apply in 2019 for a 2020 start date, and current CPC+ practices can apply in 2020 for a 2021 start date (exiting CPC+ one year early). Because PCF is expected to be an Advanced APM, non-CPC+ participants will be eligible for the 5% Advanced APM (AAPM) bonus for program years 2020–2022, and CPC+ participants who exit CPC+ and begin PCF in 2021 will be eligible for the AAPM bonus for program years 2021 and 2022. CMMI is expected to release the Request for Application this fall.


If you have any questions, please contact Dr. Austin Bailey or Paul Staley.


Network News

Introducing Anthem Cooperative Care.


Coordinated Care is excited to offer a new payer agreement with Anthem Cooperative Care. This agreement strives to achieve reductions in cost of care, improvement in quality and high patient satisfaction. The opt-in forms to participate will describe in detail the financial terms as well as the requirements of the contract.




Effective January 1, 2020, Anthem’s commercial value-based program called Enhanced Personal Health Care (EPHC) will be replaced with a new program called Cooperative Care. The agreement focuses on the same tenets of EPHC with further requirements in the area of capabilities. For example, Anthem wants to ensure practices have long-term goals for EMR integration and online scheduling.


In this program, there is a care coordination fee to close gaps in care and a shared savings component when successful in reducing cost. In later years, participating providers may be asked to take some financial risk.


Anthem will be highlighting Cooperative Care providers to their employer groups through a variety of marketing campaigns and a hierarchy in their primary care selection tool, where your name will bubble to the top.


If you have further questions, please don’t hesitate to outreach to Paul Staley.