January 23, 2020
4 min read

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Wayne Jonas
Wayne B. Jonas

In this guest editorial, Wayne B. Jonas, MD, the executive director of Samueli Integrative Health Programs and a former director of the NIH’s Office of Alternative Medicine, discusses how to adapt your practice to a health care system that is quickly shifting away from the fee-for-service model and toward value-based care. He offers tips on billing in the new payment models, which require physicians to offer care to patients that extends beyond their immediate illness.

For many practitioners, the relentless pace of change in the American health care system is highly disruptive and often frustrating. But as major new alterations in Medicare and Medicaid reimbursement are looming — alterations that move away from fee-for-service payment — we have a prime opportunity to reinvent our medical practices in ways that benefit our patients while enabling us to thrive in this new environment.

Beginning soon, we’ll see lower Medicare payments for services, yet we will also have the potential for bonuses if we meet certain quality indicators around improving chronic health issues. Therefore, our focus must not just be on treating illness but also on integrating health promotion and disease preventative through self-care into the treatment of disease. We must prepare for a value-based system that will reward us for the quality rather than the quantity of care we provide our patients.

Improved technology, expanded access and better collaboration within health care teams all reinforce this change. Far more important, however, is the potential to rethink the very nature of care by extending reliable, evidence-based and cost-efficient forms of treatment that extend beyond pills and procedures and beyond the office walls.


Research has repeatedly shown that even with full medical access, a population’s health improves only by about 15% to 20%. Our overall health and well-being come overwhelmingly from behavior and lifestyle, the local environment, and the social determinants of health. Thus, 80% of health is determined by factors outside the hospital and clinic.

More than half of the top 25 chronic conditions (hypertension, diabetes, obesity, chronic pain, anxiety, depression, etc.) can be mitigated and treated effectively with behavioral and integrative health approaches, including nutrition and movement, stress management, sleep, social support and evidence-based complementary medicine like therapeutic yoga, acupuncture and massage therapy. These approaches are far less expensive than drugs and surgery if applied in time.

How can physicians align their patient visits to produce health?

I have seen positive results in my own practice by implementing these new ways of treating patients and seeking reimbursement to cover such approaches. I have restructured my office visits to reframe the patient experience from one focused exclusively on diagnosing and treating disease to one that emphasizes prevention, health promotion and self-care. In the process, I have rediscovered the satisfaction of feeling that I am not just treating illness, but helping my patients heal.

In medical school, we all were trained to employ the SOAP note — Subjective, Objective, Assessment and Plan — and use it to chart a patient’s condition and treatment. This methodology — and the current payment system — sharply limits the ability of physicians to make healing their primary mission. So, I supplement the SOAP approach by adding what I call a HOPE note. HOPE stands for Healing-Oriented Practices and Environments. It is a quick and straightforward way for addressing a patient’s determinants of health and aligning my medical approaches with what is important to the patient. The latter is key to their ability to change behavior.

Fundamentally, instead of only asking my patients, “What’s the matter?” I attempt to get to the root of their health and well-being needs by asking, “What really matters to you?” The HOPE note process has helped me learn to listen more closely to my patients, to better understand the underlying drivers of what may be making them sick, and to help them choose their best personal path to healing. It is a tool for delivering value-based care by caring for the whole person.

How can physicians bill differently in the new payment models?

We’ve long known that interventions to encourage lifestyle changes can improve depression, hypertension, diabetes and other chronic ailments. We know that a properly delivered annual wellness visit can be used to explore and personalize what the patient wants and needs. With the coming changes in Medicare, health care providers need to be thinking about ways to both promote health and capture those needs and benefit from value-based billing models.

If an office organizes its health payment coding properly, providers can get paid for team-based care that includes helping patients in behavior change and health promotion. There are an increasing number of codes for this type of care, such as the Annual Wellness Visit, the Welcome to Medicare, and codes for weight management, hypertension, diabetes prevention and treatment, mental health conditions and chronic pain, whichcan be used to cover discussions aligned with and following a HOPE visit.


Many outpatient evaluation and management visits can be billed as counseling and coordination of care. Group visits can be particularly rewarding to lead — and they benefit the practice — by allowing us to briefly see each patient and document the visit in the chart. In value-based payment models, health and well-being service lines earn essential points under the Patient-Centered Medical Home designation by the National Committee on Quality Assurance (NCQA) and provide a new angle to improve outcomes in pay-for-performance systems such as MIPS (Medicare’s Merit-Based Incentive Payment System), which may soon be replaced by Primary Care First, the newest of the value-based approaches offered by CMS.

However, demonstrating these outcomes requires more than just coding. Designing a practice that tracks improvements in health for patients is essential. Physicians can enhance their billing code process if they gather data on patient needs in a way that aligns with a value-based model and patient-centered care. The HOPE process provides tools to assist with the latter.

Finally, how to bill and get reimbursed for the underlying social determinants of health has always been a challenge in primary care. It’s no different today. Responsibility for the health of a population is where health care is headed, and coordinating with community services outside the office is essential to make that work. We must embrace the value-based billing change that’s coming, and ultimately, learning to listen to our patients and address their issues holistically is key to our success in this new integrative model of care.

Disclosure: Jonas reports no relevant financial disclosures.