The health coaching community in the USA faces frustration with CMS’s (Medicare) reluctance to approve payment for health coaching procedure (CPT) codes. Coaches see such coverage as vital for inclusion into the health care system. But given CMS's record of being slow to make coverage decisions (it took 12+ years to expand eligibility for cardiac rehabilitation), exploring alternative business models for health coaching services seems prudent.
Health coaching holds immense potential for America's health, since interventions such as healthy eating, physical activity, meditation, sleep and tobacco cessation are the often-neglected first line of treatment for a wide range of chronic conditions. Health coaches can thus significantly enhance the effectiveness of the health care team for a large portion of the population.
Outside of CPT codes specifically for coaches, there are four general categories of coaching services:
- Covered benefits not traditionally served by coaches,
- Self-insured employers opting to cover health coaching services,
- Charity-pay consumers who require subsidies, and
- Cash-pay consumers able to afford health coaching.
Heretofore, health coaches have primarily served the 4th category, but now we need coaching to be a covered benefit so that they can be part of the health care team.
One key opportunity is for health coaches to provide covered benefits beyond traditional health coaching roles. Chronic care management (CCM), for instance, presents an opportunity because CCM is A) under-utilized and B) can be enhanced with good coaching and use of today’s digital and telehealth tools. Innovating with CCM, medical practices could compete with alternative and complementary medicine services for disease management (nutraceutical vendors, spas, dietitians, etc.).
McKinsey & Company believes that health systems doing so could tap into the $1 trillion health and wellness market in the USA (about $3000 per American per year), citing consumer dissatisfaction with traditional health care services (are you listening, doctors?) and a growing demand for personalized care as an opportunity for such innovation. While McKinsey is speaking more to the cash pay marketplace, it could be for CCM too.
Other covered benefits health coaches can perform include administering health risk assessments, participating in Annual Wellness Visits or principal care management (chronic care management by a specialist managing a particular problem), remote physiological monitoring, physical functioning screening and participating in group cognitive therapy visits for cardiovascular disease or obesity. All of these services align well with a lifestyle medicine intervention team where coaching is invaluable.
Engaging health coaches in these team-based roles provides coaches a precious opportunity to see how behaviors, social determinants or poor physical functioning are impacting the patient’s life. Such intimacy positions the coach as the go-to health and wellness resource in the practice, enhancing value in the patient’s eyes and making any out-of-pocket expenses for telehealth coaching a more worthy buy.
In the self-insured category, health systems can negotiate with self-insured employers to cover health coaching, even when CMS and private insurers don’t. Health systems can negotiate with private insurance companies and even seek a local coverage decision from their local CMS administrator. Yes, your local CMS administrator can decide to cover coaching CPT codes in your area, but to convince them to do so you've got to have your ducks in a row. You're going to want to have community support, prior to approaching these 3rd party payers, and a great way to be convincing is to collaborate with local charities with the goal of extending services to underinsured populations.
Of course, all such negotiations are much more compelling if the health system covers coaching for its own beneficiaries, which is feasible because almost all health systems are self-insured. If your system won't buy its own services, you won't convince anyone else to buy it. In all of these alternative designs, collaboration with payers and the health system’s compliance officers provide reassurance that everything the program does is above-board. Perhaps most important, any system negotiating for coverage of health coaching will need champions in the C-suite leading the way, so get those leaders on board!
Now let’s look at potential for cash paying consumers. McKinsey’s suggestion to offer cash pay services may seem surprising, as medical practices are generally reluctant to offer services not covered by payers. However, many medical practices offer cash-pay for a variety of products and services, including dietary supplements, collagen and botox injections, skin care products, massage, shoe orthotics, exercise gear, exercise testing, durable medical equipment and much more. McKinsey suggests practices partner with local wellness vendors, leverage digital technology and offer virtual services, all with the goals of improving patient satisfaction, health and well-being as well as engagement.
Tapping into that $1 trillion market will require a compelling service to compete with health spas, nutraceutical stores and other alternative and complementary health services, but you can do it! Why should anyone travel to a resort, when they can get the support they really need it - right at home? One thing that surely won’t sell is offering more medical therapy - patients are looking for holistic approaches to health, not more polypharmacy or tech to improve adherence to the doctor’s prescriptions.
To conclude, the health care community should explore ALL of these opportunities, and not sit back and wait for CMS to make up its mind. Indeed, action in this space is what CMS wants to see, and patients with chronic conditions need help now. So don’t wait, leverage as many services as possible to create a viable and sustainable business model for lifestyle medicine and put health coaches on your team. If that sounds attractive, Sustainable Health Systems is ready to help you develop such pioneering consumer-led services.
References
Buchter J, Cordina J, Eckroate J. Consumers rule: Driving healthcare growth with a consumer-led strategy. McKinsey & Company, 4/15/2024.
Reddy, A, et al. Use of chronic care management among primary care physicians. Annals Fam Med, 2020 18(5):455-457. doi: 10.1370/afm.2573
Galewitz P, Hacker, HK. Medicare's push to improve chronic care attracts businesses, but not many doctors. NPR News 4/17/2024.
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