New Revenue Opportunities in 2024

The Centers for Medicare & Medicaid Services (CMS) issued the finalized calendar year (CY) 2024 Physician Fee Schedule (PFS) policy changes, and while there are numerous elements to be cognizant of, we wanted to spotlight one revenue generating element that’s easy to overlook.

The CY 2024 PFS final rule is, as others rulings within this administration have been, focused on creating a more equitable healthcare system across the country. It added new reimbursement opportunities for caregivers supporting patients with their treatment plan; a new add-on code to address the financial hardships primary care physicians face in the event of frequent Evaluation and Management (E/M) visits; and even new Medicare Part B coverage for marriage and family therapist (MFT) and mental health counselor (MHCs) visits – all of which are expected to help improve care quality, access, and affordability for those that need it most. One element in particular piqued the interest of Connex Members, however, primarily because it creates a new revenue stream out of actions that are already routinely taken by many Providers.

SDoH Risk Assessments
As of January 1st, CMS is now reimbursing for social determinant of health (SDoH) risks assessments as part of the patient’s annual wellness, E/M, or behavioral health visit; each of these will have their own, corresponding G codes, with the E/M version receiving permanent status on the Medicare Telehealth list.

CMS did not mandate any specifically approved assessments, but did encourage the use of widely adopted and validated tools like the CMS Accountable Health Communities tool; the instruments identified for the Medicare Advantage Special Needs Population Health Risk Assessment; and the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences tool. This change coincides with those made to 2024’s Hospital Inpatient Quality Reporting (IQR) program requirements, as those participating will now be required to submit two different annual measures: SDOH-1, which is the Screening for Social Drivers of Health, and SDOH-2, Screen Positive Rate for Social Drivers of Health.

These CMS SDoH risk assessments have a work relative value unit (wRVU) of .18, translating to a national facility rate payment of $8.84, and a non facility rate of $18.66. While not particularly lucrative in a vacuum, the scale of possible recovery becomes clear once one considers assessment frequency and the speed with which they can be conducted. The process takes no more than 10 minutes – conversations with our own network of thought leaders put it closer to 5 – and can be administered every 6 months. Using the facility rate, CMS’ March 2023 enrollment figures, and assuming just one assessment is done for the 24% of Medicare beneficiaries that utilize their annual wellness visit benefits, more than $139.5 million will be up for grabs. Bringing those numbers into more tangible terms, Providers conducting the assessment at the maximum frequency of twice a year at the facility rate can expect upwards of $884,000 per 50k patients. 

Assessment Strategies
Conducting that assessment on paper forms or burying it within an EHR’s free notes field would likely make that level of reimbursement more trouble than it’s worth, as billers would need to scour through sets of unstructured data to find the necessary information. However, these assessments can be seamlessly integrated into patient access or patient encounter processes with the right resources.

Several EHRs and bolt-on modules exist that facilitate SDoH risk assessments during the patient encounter, giving clinical staff an opportunity to really evaluate and understand patient answers as they’re being given. These additional details can help contextualize the patient’s gaps and thereby improve care delivery. They can also go on to help better prepare case managers, social workers, and other post-encounter professionals in finding appropriate community resources for patients.

However, it’s likely that more time efficient options will be required. A Physicians Foundation survey in 2022 found that 61% of physicians felt they had “little to no time and ability” to effectively evaluate and address patients’ determinants of health. More than half of physicians in the survey reported that determinants of health challenges cause them stress or frustration on a regular basis, with a whopping 83% of them believing that attempts to address determinants of health directly contribute to burnout. Interestingly, 57% of those physicians identified “lack of reimbursement for screening for or addressing determinants of health” as a key source of their frustrations – hopefully the CY 2024 PFS final rule will help offset these numbers.

Considering the limited time and resources of physicians, as well as the astronomical rise in patient self-service tools even among elderly patients, it seems more likely that the ideal assessment process is one that’s incorporated into the patient access process alongside other digital patient intake forms. Additionally, conducting the assessment digitally could make patients feel more comfortable answering honestly. While the veracity of patient responses isn’t directly tied to reimbursement, having a more accurate picture of the patient’s barriers to care access and plan adherence would
lead to better outcomes, potentially improving financial performance by way of avoidance.

Going Beyond Screening
The CY 2024 PFS final rule also included new rules for reimbursement around Community Health Integration (CHI) and Principal Illness Navigation (PIN), both of which are expected to improve care coordination, health education, and patient self advocacy while facilitating access to community support resources. CHI services help address unmet SDOH needs that affect the patient’s diagnosis or treatment process, while PIN services help Medicare patients diagnosed with high-risk conditions – such as cancer or dementia – find and connect with support resources.

More specifically, these new rules address those instances where clinicians involve other types of healthcare support staff, such as care navigators, peer support specialists, and community health workers. These auxiliary personnel have always been able to perform covered services, but they now are specifically referenced through the new, finalized codes. CMS also clarified that these individuals can be employed by community-based organizations (CBOs) rather than the Provider overseeing the patient’s treatment if there’s the “requisite supervision” from a billing practitioner for these services.

The Total Financial Picture
These changes coincide with increased interest in new ways to close SDoH gaps amongst Connex Partners’ Healthcare Executive Community members. Several community discussions have addressed the fact that greater investments in SDoH and population health initiatives could help improve revenues, as they pertain to both value based reimbursements and decreased instability in care delivery. The variance caused by SDoH not only impacts clinical outcomes, but the overall cost efficiency of Providers. Common factors impacting the most vulnerable – such as transportation insecurity, lack of communication technology, and language barriers – can all hurt cost efficiency by way of missed appointments, ED overutilization, and disrupting the SDoH screening process itself.

Furthermore, there are the downstream costs associated with the aforementioned physician burnout. Frustration caused by missed appointments, lack of care plan adherence, and other SDoH-dependent problems all compound growing issues with clinician mental health and Common factors impacting the most vulnerable – such as transportation insecurity, lack of communication technology, and language barriers – can all hurt cost efficiency by way of missed appointments, ED overutilization, and disrupting the SDoH screening process itself. stress, at a time where staffing pressures don’t leave room for attrition. In fact, at an August 2023 Connex Partners Think Tank examining mental health and wellbeing for healthcare staff, one Attendee argued that staff burnout could be directly tackled by creating a more robust SDoH toolkit. Essentially, they believed that those community resources didn’t need to be confined to just patients in need – they could, and should, be made available to staff to address the various socioeconomic pressures affecting them outside of work.

Several best practices emerged within that Think Tank and others, such as having pre-established lists of community resources – like food banks – that can be given to patients once their instabilities have been identified. Ultimately though, the value of those connections is directly correlated to how much of an investment the Provider makes in establishing true connections and partnerships with community programs. The specifics of that process will always depend on the Provider’s unique local politics and infrastructure, but the American Hospital Association did publish an excellent playbook on how to foster hospital-community partnerships. While it was released prior to COVID’s disruptions to the healthcare arena, many of its
core recommendations still hold true.

Conclusion
Whether a Provider is ready to capitalize on the new SDoH risk assessment reimbursement made available by the CY 2024 PFS final rule will depend on the efficiency of their workflows; their adoption of digital, self-service, and other automation tools; and their ability to forge relationships with the community resources that can close SDoH gaps within their markets. Those that do make the necessary investments, however, will likely see an increase in revenue thanks to a simple process they may already be doing; improvements in overall patient outcomes and a decrease in the amount of frustration and stress shouldered by clinicians.