Every day, doctors, nurses and administrative staff work under the adage, "Where there’s a will, there’s a way.”
They’re paid to provide clinical care to patients in need, but sometimes those patients also struggle with personal challenges or circumstances beyond the medical issues that get in the way of that care. At such moments, extra support can make all the difference in the world.
So, while it may not sound glamorous, the Center for Medicare and Medicaid Services’ (CMS) decision to reimburse Principal Illness Navigation services has the potential to be transformational and to significantly impact the quality of care that high-need patients with long-term illnesses like cancer or diabetes receive. “PIN”, as it is known, will reward providers for the extra support that many are already giving patients at a cost to their own bottom line. These new reimbursement codes are a major step forward toward recognizing patient navigation as a critical component of healthcare. Real effort, money and legislation has finally been put behind these services, and we applaud CMS’ efforts.
PIN is not a cure-all, however. Its true impact will need to be assessed in the context of how far it goes to meet CMS’ larger goals around value-based care.
Making the case for care navigation
For both of us, our years of caring for cancer patients and being a cancer survivor has reinforced for us what people with cancer know all too well, that a long care journey can become overwhelming as stamina, health or life circumstances change. Suddenly, it can feel impossible to follow a care plan, coordinate referrals or new appointments, get groceries or keep up with the bills.
Through our combined decades of experience as a medical oncologist and a primary care physician, we’ve watched this play out from both the patient and provider side. We know that the moment patients leave the office, something almost inevitably breaks down – whether they don’t understand how to manage their symptoms or side effects, or they can’t get a ride or find childcare in order to make it back for their appointment. This is especially true for people who already face challenging socioeconomic circumstances and are even more vulnerable to life’s difficulties. Making a choice between paying for medications or for rent and food is a decision no one should have to make.
While these problems are not the provider’s direct responsibility, they can spell the difference between a patient getting better or getting worse. If noticed, someone at the clinic will often go the extra mile on the patient’s behalf – spending hours a day calling social services organizations, arranging for transportation, getting hold of cheaper medications or setting up virtual care visits. They have the will to help their patients, so they find the way. For an individual patient, that can make all the difference in the world.
Those efforts also yield returns on a broader scale. Patients who get sicker because they can’t access care or afford their medications often require more intensive treatment, frequent ER visits or even hospitalization. This increases total care costs and strains clinical resources while diminishing the quality and possibly even the length of that patient’s life. Under traditional Medicare reimbursement, providers aren’t reimbursed for addressing those risks preemptively despite the societal benefit. And yet, the time and effort spent addressing nonclinical needs also adds to the administrative burdens providers already struggle to manage. Many don’t have the resources or personnel to offer that kind of support on a routine basis.
That’s why CMS’ rare decision to issue new reimbursement codes for PIN services should be applauded. Recognizing patient navigation as a billable service for 2024 will enable providers to pay for patient navigators who can support patients with serious, high-risk, longer-term conditions, illnesses or diseases. With “will” and “way” aligned at last, these navigators will be able to facilitate access to social services, coordinate care transitions and offer the kind of person-centered care and holistic support many patients need.
Beyond billing: Easing the challenges of integrating patient navigation programs
Like any significant new policy proposal, however, PIN also presents questions and challenges that should be considered and addressed for the program to really move the needle on patient care.
The first and most fundamental challenge will be to minimize the administrative burden on providers. PIN, like any new reimbursement code, will likely require a lot of documentation. Providers will need to hire dedicated navigators or third parties to offload the reporting and to update the patient’s medical records. PIN could easily turn navigation into a documentation and checklist exercise that prioritizes paperwork over patients if not implemented correctly.
Another challenge is that navigation services have traditionally not been easy or simple to provide. Although some organizations, especially large hospitals and health systems, have the resources and finances to implement navigation programs, that’s not always the case for smaller practices and community clinics. Patient navigators have complex jobs. To be effective, they must get to know the patient’s unique circumstances, such as whether or not they have access to transportation or the ability to eat nutritious food. They must have exceptional problem-solving skills and resourcefulness to identify a need before it becomes a problem.
For example, a patient who misses their chemotherapy appointment simply because they could not get a ride to the office means they are likely to end up in the emergency room later on. A navigator would have needed to have discovered the transportation issue days before the patient's appointment and connected them to a medical transportation service to take them to the clinic.
Navigators must have ready access to an established network of social service providers, accurate and timely information at their fingertips, the ability to facilitate or coordinate referrals and schedules and channels for communicating with care teams about treatment plans and medications. For small practices without the staff, resources or infrastructure to do this at scale, the idea of implementing patient navigation services — and taking advantage of PIN reimbursement — can seem daunting and expensive. All hope is not lost, however. There are technologies and systems available that can relieve the administrative burden and logistical complexities to the benefit of practices and their patients.
Balancing short-term goals with long-term vision
Perhaps the most important step that CMS must take to ensure PIN succeeds, however, is integrating such services within CMS’ larger goal of enrolling every Medicare and Medicaid beneficiary in accountable care relationships by 2030. Value-based care has long represented what healthcare should have always been about: better patient care at lower total costs. Under such arrangements, providers are rewarded for achieving quality outcomes that do not exceed specific cost ceilings. This encourages providers to offer the kind of preventive and holistic care that helps patients avoid conditions from becoming more acute and keeps them out of hospitals and ERs.
CMS’ 2030 strategic plan is intended to influence providers and payers to adopt and align around value-based payment models, through the creation of comprehensive and sustainable voluntary programs. To that end, PIN services are tailor-made to improve care quality and health outcomes by helping patients adhere to their treatment plans, address their health-related social needs, and make their appointments. But PIN could also increase care costs unnecessarily if they are applied to patients who don’t need them and won’t benefit from the extra support.
Sticking to the plan
This is U.S. healthcare’s fundamental conundrum. How can patient health and experience be improved even as costs get curbed or reduced? Fortunately, the answers seem to be within reach. Rather than function as a separate policy measure, PIN services must be an integral part of CMS’ 2030 drive to value-based care.
This will motivate providers to offer high-value PIN services that really make a difference on care quality and costs, rather than merely driving up reimbursement. It will reduce documentation requirements because payment will no longer be tied to the services offered. And it will encourage new companies to meet the market need for quality navigation by offering innovative, cost-effective support to care providers.
CMS already has several models for how this can work in areas like complex kidney care and cancer. Its newly initiated Enhancing Oncology Model (EOM), for example, has been designed to encourage oncology practices to develop the capabilities necessary to participate in value-based care. Patient navigation services are specifically called out as essential in that effort.
CMS’ proposed reimbursement of navigation services for patients with complex, long-term conditions is a major step toward better patient care and experience. But to really work, PIN must be part of CMS’ greater vision for value-based care.
Co-authored by Dr. Bobby Green, medical oncologist and co-founder, president and chief medical officer at Thyme Care and Dr. Brad Diephuis, primary care physician and chief business officer at Thyme Care