Value When Billable Units are King?

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The Question

A subscriber shared that they have limited exposure to value-based care and asked:

“How do we get value in a world evaluated by billable units, and with little to no multidisciplinary conversation?”

This question surfaces two foundational tensions in U.S. healthcare delivery:

1. The dominance of fee-for-service reimbursement

2. The structural barriers to meaningful interdisciplinary collaboration

Both are central to why value-based care exists in the first place.

Fee-for-Service and the Absence of Incentives for Health

Under fee-for-service, providers are not reimbursed for improving long-term health or preventing illness unless a billable service exists. Historically, those services did not exist.

While the Affordable Care Act introduced several preventive and care management codes—Annual Wellness Visits, Advance Care Planning, Chronic Care Management—these remain transactional constructs layered onto a fundamentally reactive payment system.

Even these newer codes introduce operational friction:

• Copays apply to most services

• Ongoing patient consent is required

• Practices must track time, outreach, and documentation meticulously

The result is incremental progress within a structure that still prioritizes volume over outcomes.

Why Billable Units Are Transactional by Design

Understanding this requires historical context.

Fee-for-service reimbursement traces back to early Blue Cross and Blue Shield models, which were designed to mitigate utilization risk. Insurance coverage focused on discrete, verifiable events—hospitalizations, procedures, physician encounters—where costs could be predicted and controlled.

Preventive and cognitive services were deprioritized not because they lacked value, but because they were harder to quantify and considered easier to overutilize. Their inherent value was not appreciated at the time.

The unintended consequence was a system that systematically undervalued prevention and coordination while incentivizing reactive care. This imbalance was later codified through the RVU framework adopted by CMS in the 1980s, which continues to weight procedural services more heavily than cognitive or longitudinal care.

CPT, Professional Self-Governance, and Structural Bias

Following the creation of Medicare, the AMA developed CPT codes to standardize physician billing. Physicians themselves determined which services warranted codes and how those services were valued.

Early CPT development focused on procedures and surgeries. Comprehensive preventive care billing emerged decades later. For example, Medicare did not cover Annual Wellness Visits until 2011 after passage of the Affordable Care Act.

The result is a structural legacy in which reimbursement remains misaligned with population health goals, despite incremental policy corrections.

Showing Value Before Taking Risk

One assumption that persists in healthcare is that value-based care requires downside financial risk to be legitimate.

That assumption deserves some scrutiny.

In practice, many effective care models improve outcomes without immediate risk transfer. They focus on access, clinical execution, care continuity, and follow-through. Value is demonstrated operationally before it is formalized contractually.

Risk can and usually does accelerate alignment, but when introduced prematurely, it often exposes infrastructure gaps rather than driving improvement. There needs to be a stepwise approach to adopting risk.

The sequence matters:

1. Build the care model

2. Demonstrate outcomes

3. Align payment mechanisms

Not the reverse.

Multidisciplinary Communication: From Checkbox to Signal

My experience in home health illustrates this clearly.

Medicare-required verbal plan-of-care reviews with physicians were largely perfunctory. Unless a specific clinical issue required intervention, these calls added little value and consumed time on both sides.

When communication was clinically meaningful, such as for medication reconciliation issues and specific safety concerns, it was necessary and appropriate. But those moments were the exception, not the rule.

Doctorally prepared clinicians like PTs operating within their scope do not require (clinically speaking) redundant physician sign-off for clinical validity. They require signal-based communication, not checkbox compliance.

What Value-Based Care Enables Operationally

In value-based environments, interdisciplinary communication is expected to be:

• Asynchronous when appropriate

• Routed through the most effective channel

• Actionable for downstream care teams

A physical therapist’s functional assessment can inform transitional care management outreach. A nurse care manager can reinforce follow-up, coordinate home-based services, and close gaps without unnecessary physician interruption.

This is all operationally achievable when care teams are resourced and empowered.

Why This Is Not the Default

Because it requires investment.

Care coordination, nurse-led outreach, and technology-enabled communication are cost centers under fee-for-service. They become assets only when outcomes matter financially.

Value-based arrangements, often through ACO participation, create the economic conditions for this work. Preventing avoidable admissions and readmissions generates shared savings that can be reinvested into care teams.

Historically, practices have been expected to front these investments themselves, sometimes through loans or advance investment payments tied to future performance.

A Note on CMMI and Infrastructure Support

CMMI exists to test alternative payment and delivery models, including what services can be reimbursed.

Newer models, such as LEAD, acknowledge a critical reality: sustainable care transformation requires upfront, predictable funding. Providing non-reconciled infrastructure payments allows practices to build care models without assuming immediate financial risk.

This represents a meaningful evolution in CMS policy thinking.

CMMI is still young, but its role in shaping future payment structures should not be underestimated.

Final Thoughts

The question posed in my survey was not how to bill differently. It was how to deliver value in a system optimized for transactions.

The answer is not to wait for perfect payment alignment.

It is to design care as if outcomes matter, demonstrate value operationally, and allow reimbursement models to evolve in response.

That work can, and should, begin now.

Appendix

Here is the present list of covered preventive services in Medicare.

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