Provider Insider

Issue 8

Table of Contents

Leadership Message

Happy 2020 everyone!


The new year brings new challenges and in this edition of our newsletter, you will find information supporting many of our key endeavors—chief among them our work to diligently curb medical costs in three arenas: inpatient utilization, emergency department utilization and pharmacy.


Our Pharmacy Integration content explores in-depth the advantages of improving our rate of prescribing generic alternatives to trade name drugs when clinically appropriate. Because pharmacy costs are rising more rapidly than any of the other cost drivers, the impact of this effort can lead to significant contributions to a shared savings pool. Even though it may seem insignificant at the time of the clinical encounter, every appropriate generic prescription counts!


Effective management of the care transition from inpatient admission to the return to the primary care provider will be essential to efficient use of hospital care. Within Clinical Programs, you will find further discussion of our evolving transitions of care program in the form of Frequently Asked Questions.


A huge thank you to all who are working to reduce unnecessary emergency department utilization. If you haven’t yet attempted to tackle this problem, we encourage you to test one of the strategies some of our providers have already implemented:

  • Some of our clinics have improved patient access to care by making changes to their scheduling template and/or adding office hours.
  • Other clinics have utilized our patient education materials, customized to their practice, to make patients aware of alternatives to the ED.
  • Still other clinics have created their own materials supporting this initiative.

Within Value-Based Contracts, you will find reviews of the new programs coming to our network from Anthem. Cooperative Care will replace Enhanced Personal Health Care (EPHC) on the commercial side and a new population of patients is being added to our Medicare Advantage program.


As always, the 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.


Austin Bailey, MD

Medical Director, Population Health

Coordinated Care

Letter from the President

Dear Colleagues,


As we look toward a new year, I wanted to reach out to all of our valued Coordinated Care providers and partners to discuss our shared goals of improving patient outcomes and reducing total cost of care.


I understand our success in each value-based contract is dependent on the active participation of practicing physicians. Those of you who are at the exam table see firsthand where improvements can occur. While we can each make small changes individually, your active participation and willingness to share ideas are critical if we are to bring permanent, systemic change to the health care system.


Our governance structure calls for a Board of Directors with board-appointed committees, and we are committed to using this framework to ensure the physician voice is both heard and acted upon; however, a structure is only as good as those participating in it. I urge those physicians with excellent ideas and a desire for broad improvements to join in leading our organization.


We currently have openings on the clinical committee and finance and contracting committee:


  • Clinical committee:

The clinical committee’s primary responsibility is to review and recommend clinical programs that deliver on the quadruple aim. The committee works to improve the coordination and integration of clinical care across provider groups, promoting high-quality, cost-effective and value-added services. The clinical committee works closely with the finance and contracting committee to ensure payer agreements and provider incentives align and support the care model.


  • Finance and contracting committee:

The finance and contracting committee’s primary responsibilities are to review and recommend for Board approval managed care contracts with payers, and to develop a performance payment model that aligns participant incentives in a way that creates value for participating providers and achieves quadruple aim goals. The committee also reviews and recommends the annual financial plan for Board approval. This committee works closely with the clinical committee to ensure payer contracts, incentives and operations support the care model.


If you would like to know more, please contact either Dr. Austin Bailey or Paul Staley. They would be happy to discuss the specifics of committee responsibility and answer your questions.


Thank you for your ongoing participation in our network.




Michael A. Cancro

President, Coordinated Care

Services and Information

Services provided to Coordinated Care members.


Your membership in Coordinated Care offers you access to competitive, value-based contracts. Did you know it also includes a number of other services managed by a centrally located team? A comprehensive list follows; for more information about any of these services, please contact Paul Staley or Austin Bailey.



  • Manage the incoming and outgoing distribution of payments to physicians.
  • Reconcile the attribution files from payers.
  • Produce modeling and financial analysis for various payment methodologies and contracts.
  • Budgeting and oversite of CIN expenses.


Payor contracting:

  • Negotiate value-based contracts.
  • Provide network rosters to payers.
  • Monitor contract performance with finance.
  • Monitor payer rosters, for narrow network alignment.


IT support:

  • Population Health modules utilized in Epic.
  • Provide Epic dashboards for contract and clinical activity performance.
  • Integrate CORHIO clinical data for CIN attributed lives.
  • Training on Epic tools and resources.
  • Cost and utilization dashboards.


Network engagement, marketing and communications:

  • Monthly performance and payer feedback communication.
  • Analyze data and provide site-specific feedback.
  • Education and printed materials for physicians and staff on value-based contracts.
  • Education on best practices for physicians and staff.
  • Patient education on value-based topics.
  • Monthly newsletters to physicians and staff.


Data analytics:

  • Gaps in care reporting.
  • Performance reporting.
  • Practice performance trending and comparisons with other CIN participants.
  • Physician roster and attribution reconciliation.


Centralized care team:

  • Complex care management.
  • Care management and care coordination workflows and best practices.
  • Post-acute care monitoring.
  • Transitions of care.
  • High- and medium-risk follow up.
  • Gap closure support.
  • Training for physicians and staff.



  • Pharmacy gaps assistance.
  • Monitor high-cost drugs by practice.
  • Education of pharmacy impact.
  • Developed Epic tools to identify patients in need of pharmacy intervention, document, and aggregate clinical pharmacy interventions for position justification.
  • Medication education and comprehensive medication review of patients.
  • Generic usage trending by practice.
  • Brand formulary compliance.


Clinical Programs

Transitional Care Management—Frequently Asked Questions (FAQs)


Why is transitional care management (TCM) important?

Transitioning care effectively is a core competency for all high-performing, value-based organizations, regardless of payer mix. Transition of care support is pivotal to achieving the Quadruple Aim:


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

The level of medical decision-making and the time frame for the face-to-face visit determines which CPT code to use (e.g., if the patient requires moderate complexity decision-making and is seen within seven days post-discharge, 99495 must be used).


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

This code 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.


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

At a 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)—more information on medical decision-making can be found below.


What care settings qualify for TCM?

Patients discharged to their home from the following settings qualify for transitional care management:

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

Can a provider bill for a TCM visit for both new and established patients?

Effective February 2013, TCM codes can be billed for new and established patients.


What are the three components required to bill a TCM?

  1. An interactive contact by the physician or clinical staff with the patient and/or caregiver via telephone, email, or face-to-face to address needs beyond scheduling follow-up care.
  2. Certain non-face-to-face services must be furnished by physicians or APPs. For example:
  • Obtain and review discharge information.
  • Review the need for, or follow up on, pending diagnostic tests and treatments.
  • Interact with other health care professionals who will assume or resume care of the patient’s system-specific problems.
  • Provide education to the patient, family and/or caregiver.
  • Establish or reestablish referrals and arrange for needed community resources.
  • Assist in scheduling required follow-up with community providers and services.
  1. Face-to-face visit within 14 days of discharge. The CPT code is determined by the level of medical decision-making (moderate or high) and if the follow-up appointment was within 7 days or 8-14 days post-discharge. Medication reconciliation must be completed on or before the date of the face-to-face visit.


What does the Coordinated Care central care management team do regarding TCMs?

The clinically integrated network has developed a centralized population health care management team that can support practices in these workflows. They have begun delivering a daily discharge list of value-based contract attributed lives to practices and will work on delivering these to all practices this coming year. They have also begun providing TOC calls for a couple practices utilizing best practice scripting and assessment tools.

Pharmacy Integration

Januvia (sitagliptin) for diabetes treatment: A $450,000 annual cost opportunity.


Dipeptidyl peptidase-4 (DPP-4) inhibitors, e.g., sitagliptin, saxagliptin, linagliptin and alogliptin, are commonly prescribed medications for the treatment of type 2 diabetes, with the most common being Januvia (sitagliptin). Unfortunately, Januvia provides limited A1c lowering of 0.5% to 0.7%, costs approximately $5,000 annually, and does not have evidence supporting positive cardiovascular (CV) and renal outcomes. Considering its limited A1c lowering, high cost and lack of additional clinical benefits, the DPP-4 inhibitors have lower value (i.e., benefit/cost) relative to other diabetes treatments, such as SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) and GLP-1 agonists (liraglutide, exenatide, dulaglutide, semaglutide, lixisenatide). In the Anthem Cooperative Care program, there are at least 90 patients prescribed Januvia, which represents an annual cost of $450,000 for this treatment.


The competition.

As can be seen in Table 1, Januvia and other DPP-4 inhibitors lack the CV and renoprotective benefits found with SGLT2 inhibitors and GLP-1 receptor agonists. As an example, treatment with Victoza (liraglutide) is known to reduce the risk of major adverse cardiac events (MACE). For every 44 patients treated with Victoza over a period of three years, one hospitalization for MACE can be prevented.1 This data is not available for Januvia or other DPP-4 inhibitors, representing a preference for GLP-1 agonists and SGLT2 inhibitors in diabetes treatment.



Optimizing the use of Januvia.

Januvia should be reserved for patients without established ASCVD or CKD who are 0.5–1.0% above their individualized A1c goal, and who cannot tolerate other oral options such as pioglitazone or sulfonylureas. Preference should be given to GLP-1 agonists and SGLT2 inhibitors which lower A1c more and have been shown to provide CV and renal benefits.


Consideration should be given to stopping Januvia in patients with A1c 0.5% or more below their individualized goal, particularly in older adults. Many older adults are treated well below their HgbA1c goal and are at risk for hypoglycemia. Data shows that around 25,000 emergency department visits and 11,000 hospitalizations annually are attributed to treatment-associated hypoglycemia among patients over 65 years of age.3 In fact, hospitalization rates for hypoglycemia surpass those for hyperglycemia in older patients.4


Brief case examples:

  • 81-year-old patient with A1c 6.1% on metformin, Januvia and pioglitazone. Her individualized A1c goal is <8% with no hypoglycemia events.
    • Consider deprescribing Januvia as A1c is far below goal. Recheck A1c in 3 months to ensure patient remains at goal.
  • 68-year-old patient with A1c 7.6% on maximum doses of metformin, pioglitazone, and Jardiance (empagliflozin). In the past, he has tried glipizide (caused severe hypoglycemia) and two GLP-1 receptor agonists (caused severe nausea/vomiting). He has no CV history.
    • Start Januvia as he is 0.5–1.0% above his A1c goal, has no CV disease and no compelling indication to try another GLP-1 agonist, and minimizing risk of hypoglycemia is especially important.
  • 59-year-old obese patient with A1c 8.6% on maximum doses of metformin and glipizide. She adamantly refuses injections. She also has CHF and CKD (eGFR 40). She asks you if Januvia would be the next best option for her.
    • An SGLT2 inhibitor (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) would be better than Januvia due to their renoprotective effects, benefit in CHF, better A1c reduction and weight-loss effects.


Key takeaways:

  • Considering its limited A1c reduction, high cost and lack of demonstrated CV and renal benefits, Januvia (sitagliptin) has low value relative to other non-insulin diabetes medications.
  • Overtreatment of patients with diabetes can increase patient and health system costs from hospitalizations for hypoglycemia.
  • Changing from Januvia to an alternative agent, or deprescribing Januvia for select patients, can have long-term financial benefit for patients and health systems.


Please contact Joseph Vande Griend with any questions.
Vivian Cheng, PharmD, BCPS, PGY2 Ambulatory Care Pharmacy Resident, authored this article.



  1. Verma S, et al. Effects of Liraglutide on Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus With or Without History of Myocardial Infarction or Stroke-Post Hoc Analysis from the LEADER Trial. Circulation 2018;138:2884-94.
  2. American Diabetes Association. Standards of Medical Care in Diabetes 2019. Diabetes Care 2019;42: S1-S147.
  3. Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med2011;365: 2002-12.
  4. Lipska KJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med2014;1116-24.
  5. American Heart Association News. “Uninsured patients faced devastating hospital bills for heart attack, stroke.” November 13, 2017.

Value-Based Contracts

New Programs from Anthem


As most of you are probably aware, January 1, 2020 brought the end to our participation in Anthem’s commercial value-based program Enhanced Personal Health Care (EPHC). The network was successful over three program years in improving quality outcomes and generating savings that were shared among network providers.


We are replacing EPHC with a new commercial value-based program from Anthem titled Cooperative Care. Structured similarly to EPHC, prospective payment is made available as well as potential for shared savings. What is different is the inherent construct of “capabilities.” These are necessary abilities that participating practices must work to employ to be able to participate in the program over time. We will be working with each of our member practices individually to help develop these capabilities.


Cooperative Care’s capabilities are divided into four domains:


Quality metrics will also be employed in Cooperative Care, but unlike the 31 quality metrics of EPHC, Cooperative Care will have eight quality metrics.


Cooperative Care will have eight quality metrics:


• Emergency department visits
• Controlling high blood pressure
• Diabetic hemoglobin A1c control
• Acute admissions for select conditions
• All cause 30-day readmission rate
• Opioid management
• Depression screening and follow-up plan
• CG-CAHPS survey administered to random patients by Anthem


We will work with individual member practices on process improvement plans for each of the quality metrics.


Our Medicare Advantage program with Anthem has also changed. One year ago, Anthem won the contract to provide benefits to the Public Employees Retirement Association of Colorado (PERA). As of January 1, 2020, all PERA patients in your practices will be enrolled in our Anthem Medicare Advantage value-based program. This is a sizable population of patients and will augment the total attribution of each of our member practices. Now that each practice will be receiving prospective payment for all of these Medicare Advantage lives with Anthem, there should be significant increase in net revenue to each practice.


Because this additional patient population changes the risk profile of the entire Medicare Advantage population and hence the prospective payment the Network receives from Anthem, we will treat this as a new program option for the practices. As such, we will offer the option to each practice to “opt-in” to participation in Anthem Medicare Advantage, even if you have participated in the past.

Network News

Welcome new members!


We are pleased to welcome Mountain View Family Medicine to our clinically integrated network.


Mountain View Family Medicine offers preventative health care and pediatric and adult health care services to patients in Fort Collins and surrounding areas. A locally owned, family medical practice with six providers and additional support staff, this clinic caters to all age groups providing:

  • Acute, same-day appointments.
  • Care for all ages: children, adolescents and adults.
  • All ages orthopedic care, dermatology and psychological evaluations.
  • Pediatric and young women’s gynecology.
  • Men’s/women’s health and hormone supplementation.
  • Vaccines and travel medicine.
  • Minor procedures, skin biopsies and lesion removals.

Other new clinics joining our network include:

UCHealth Primary Care – Highlands Ranch


Coordinated Care includes primary care practices and hospitals from Pueblo to Steamboat Springs and is comprised of more than 600 providers and 100,000 attributed lives.