Albert Einstein famously said, “In the midst of every crisis, lies great opportunity.” When the COVID-19 pandemic struck the United States in March 2020, ambulatory care providers quickly discovered that a good deal of health care could be delivered virtually. In the span of just a few weeks, providers moved much of their ambulatory care to telemedicine or virtual interactions. Almost 40 percent of patients have received care via a telehealth visit in 2022.

But now the real work lies ahead as both ambulatory care managers and new digital entrants alike move from a crisis mindset to a mindset of planful redesign in which they’ll find the optimal balance between virtual and in-person care. Key to this process will be to redefine what constitutes a “visit.” To build the care delivery system of the future, which will focus on value and outcomes, we must first liberate the billing system and reimbursement models from the handcuffs of synchronous interactions in specific “places of service.”


Defining A ‘Visit’

The history of billing in the US health care system is paying for units of time, all oriented toward synchronous interactions between patients and providers in readily identifiable locations such as hospitals and clinics. This system presents several problems. First, the work that gets performed in between visits doesn’t get rewarded. This wasn’t much of a problem back in 1966, when the first version of Current Procedural Terminology (CPT) was published. A few minutes spent calling in a referral or answering the occasional patient call was included in the visit fee.

But consumer patterns and preferences have changed a lot since then. In 1966, even the lowly fax machine had yet to make its way into doctors’ offices. Yet today, at the University of California, San Francisco, the number of messages received by ambulatory clinicians via MyChart has increased 500 percent since 2016.

Given the way communications between physicians and their patients have evolved, it’s time to transform fee-for-service billing models to accommodate asynchronous physician-patient encounters. At first blush, this sounds impossible given current constraints. Yet, there is a solution: Instead of defining a visit as a single, in-office encounter, redefine it as a period of time spent working on a case and have that period of time serve as the billing unit.

For example, let’s say we redefine a visit to an increment of two weeks. When an encounter with a patient begins (either via synchronous or asynchronous interaction), the clock starts for billing purposes. Instead of submitting a claim for X dollars for the Y minutes of time on a particular day in a specific location with a patient, the practitioner submits a single claim for two weeks of both synchronous and asynchronous patient interactions and associated work. At the end of the two-week period, the physician is reimbursed—not for every minute spent answering email or making referrals or performing in-person examinations, but for a fixed fee linked to a single two-week unit of time. This would reimburse for the physician’s training and expertise, not minutes spent live with patients.

Of course, even if the physician does not bill for each patient interaction, it would still be necessary to track patient care delivered within the time window. Fortunately, today’s health care information technology systems already capture data related to both synchronous and asynchronous patient-physician interactions. With minor modifications to these systems, as well as changes to the billing coding systems, existing platforms and technologies could be used to ensure accountability and to create digital records for use by payers and regulators.


Catalyzing Further Shift To Value

Counterintuitively, this innovation in fee-for-service billing would not only be transformational for virtual care but have a secondary impact by accelerating the transition to value-based payments. To build a cost-saving care model against one’s risk contracts, it’s imperative to enable both synchronous and asynchronous care. Yet, if fee-for-service billing codes do not accommodate asynchronous care, this presents the provider with a vexing challenge: the requirement to operationalize two fundamentally different care models within the same clinical setting, in which one model, virtual, has iffy chances for reimbursement. This practical reality is a fundamental reason many fee-for-service providers have struggled as they’ve taken on at-risk arrangements for subsets of their patients. If fee-for-service billing were to allow for asynchronous care, it would better align with the shift to value.

Moreover, this system would reward physicians for providing a holistic care regimen over a period of time, rather than just treating a single ailment. If “a visit” constituted two weeks, physicians would no longer be under pressure to wrap up each patient encounter in 15 minutes. Rather, physicians would be rewarded for the time between in-person visits, when they perform such vital work as returning emails, interpreting test results, and asking for consults. These incentives are similar to “best-in-class” at-risk care models.

In conclusion, it’s high time that providers of ambulatory care leave behind the artificial divide between telemedicine and traditional medicine. As a result of the COVID-19 crisis, we’ve already laid the foundation of a new way of operating and blending both in-person and virtual care. Regulators and policy makers can facilitate this by fostering policies for asynchronous—and not “building-bound”—billing layers on top of the current fee-for-service infrastructure.

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