Stepping Outside the Box - Part II

Geoffrey E. Moore, MD FACSM

Part II: Enhancing Your Health and Well-being Business Model

In Part I, we covered how to navigate billing rules to your advantage. Now, in Part II, we'll delve into strategies for making your health and well-being service model a resounding success.

Boost Your Team with Lifestyle Expertise

After three years as a solo practitioner, I was recruited to lead a cardiac rehab program at a community hospital. I had previously been the medical director of cardiac rehab at the University of Pittsburgh, but my vision extended beyond heart disease. At that time, payers only covered cardiac rehab services for 3 specific diagnoses – following a heart attack, after coronary artery bypass surgery, and angina pectoris (chest pain due to coronary artery disease). I wanted to offer services to people who had any chronic condition, and fortunately was able to persuade the hospital to establish this clinic. An essential part of the operating model was utilizing non-physicians to provide billable services.

Our health and well-being service line gave us the potential to move from a provider-only billing model to a team-based model. I had learned during my internal medicine residency that I wasn’t scalable and couldn’t do everything in caring for my team’s patients. Here, as in my residency, my job was to delegate responsibility and provide backup when someone needed help. 

Transitioning to team-based care requires letting go of the notion that all services have to be led by a physician, and embracing the notion that the practice team is backed by a physician. The physician must learn how to lead from behind, putting the spotlight on the staff and not themself. Doctors, your patients will know that you are the one who made it possible. You should, however, learn about the pillars of healthy living, as promoted by the American College of Lifestyle Medicine.

Health coaches, health educators, nutritionists and exercise physiologists can be key members of such a team. Many practices already employ staff members and nurses who have an interest lifestyle interventions. Empowering these allied health care professionals is the only way to scale health and well-being services profitably at an affordable cost. 

Harness the Power of Group Visits

My experience with the power of group visits got started during my solo practice years, when I encountered a couple seeking weight loss. I proposed conducting shared visits and their payer readily agreed, especially since they were spouses. I learned to extend this approach to unrelated patients, which only requires that all participants have consented to maintain privacy.

Transitioning to shared appointments, or "group visits," was a game-changer. Patients in group visits learned from their peers, collaborated on making positive changes, and provided each other emotional support. None of these peer-driven dynamics were achievable with individual visits. [Wadsworth] Group visits also significantly boosted practice productivity, though conducting successful sessions required me to improve my skills. Navigating the dynamics of diverse backgrounds and experiences of the participants demanded skill and finesse. Also, group visits naturally fit a structured mini-course format.

In our group visits for lifestyle intervention, we billed based on time using evaluation and management (E&M) codes with the provider leading more than half of the group visit. Didactic segments were led by dietitians, nurses and health educators (a health coach or exercise physiologist could do didactic segments, too). Our nurse practitioners and I could see far more patients than we could individually in the same amount of time.

To facilitate group visits, the staff member who led the didactic portion of the visit assisted as a scribe, ensuring prompt completion of progress notes after each session and reinforcing the feeling of team-based care. A 60-75 minute session with 6-8 participants provided an optimal environment for group dynamics and workflow, and met the requirements for level 3 E&M visits. 

Maximize Staff Contributions Using Annual Wellness Visits (AWVs) as Recruitment Opportunities

Now, let's supercharge your health and well-being services! Section 4103 of the Affordable Care Act allows non-physicians like health educators, dietitians, or nutrition professionals to perform annual wellness visits (AWVs) under a physician's supervision. A major aim of AWVs is to provide referrals to health interventions that reduce risk factors and improve disease self-management.

Consider the implications for your business. Staff members, with lower costs than physicians, can conduct AWVs and generate the same revenue (i.e., be more profitable). They can also refer patients to your program and be the staff participating in group visits, becoming catalysts for your health and well-being service line.

While many primary care doctors enjoy performing AWVs, having allied health professionals do AWVs has its rewards. It makes health and well-being services highly profitable, improves individual and population health, boosts patient engagement, satisfaction and well-being, and offers physicians the potential of very fulfilling experiences in leading group visits.

In Part III, we'll explore how to leverage technology and garner support from your C-suite to further enhance your health and well-being service line.



KH Wadsworth, TG Archibald, AE Payne, et al. Shared medical appointments and patient-centered experience: a mixed-methods systematic review. BMC Family Practice 2019;20:97.