Thinking Out Loud: Anatomy of a Regulation

As a physician, I know how convoluted and complex navigating a patient seeking care in our health system can be. Having provided that care for decades, I consider myself Sherpa-like in the ability to navigate the Everests of getting appointments, assuring the necessary documentation is available to specialists, obtaining pre-certification, and fighting denials. To extend my metaphor, I must have been a version of Tenzing Norgay, the Sherpa who climbed with Sir Edmund Hillary up Everest, because forty years after entering practice, Medicare has determined that all that guidance is a billable service. Navigation services, 

“…refers to providing individualized help to the patient (and caregiver, if applicable) to identify appropriate practitioners and providers for care needs and support, and access necessary care timely, especially when the landscape is complex and delaying care can be deadly.”

Medicare will compensate physician practices ‘for the time, effort, and expertise required” to navigate complex care at roughly $80 for the first hour and $50 for an additional 30 minutes. The Principal Illness Navigation (PIN) codes are part of chronic care management and can be billed by multiple physicians caring for a patient monthly.

Once an individual receives in-person care from a physician, PIN services can be provided simultaneously or remotely through telehealth services. [1] The services can be provided by a nonclinical worker under the supervision of a physician. The navigator must be certified or trained, but that certification is left to the States to determine. Some organizations offer the training and certification for free, while others charge a fee. Of course, with no central authority, standards will vary. 

It is illegal for a physician to waive patient co-payments (although those co-payments are often written off as non-collectible debt). So it will cost patients about $15 to get help in getting the care they need – care that includes resources for food, transportation, and “charity care” along with the nuts and bolts of appointments and care coordination. As the authors of a viewpoint on PINs point out, even this nominal cost can be challenging to the financial resource-limited, making these services “most pertinent to the patients who can afford the copay the least.”

Insurance coverage adds another layer of complexity. The minority of Medicare beneficiaries with traditional Medicare will have to meet their copay obligations; those with a supplemental program, will find the co-payment covered within their plan. The majority of Medicare beneficiaries, now enrolled in Medicare Advantage, may or may not find PIN benefits at all. However, MA programs already provide navigation services to those with significant chronic conditions – those whose health costs are so high that managing them is necessary for the plan's fiscal health. 

The underlying need for PIN codes is the fractionated care our health systems provide, compounded by optimization directed more at reducing system expenses than facilitating care. The “patient-centered” and “patient-empowering” automated telephone trees and online scheduling of appointments are ways to lower front-office costs and do little to empower patients. The use of Medicare’s Relative Value Units (RVU) to calculate payments based on resource utilization does not account for the need for navigation assistance or its costs. That is why PIN codes were devised to provide another layer of reimbursement to patch a dysfunctional system.

As another revenue stream opens, the influx of fiscally hungry already exists. 

• Specialties involved in complex care, including primary care, oncology, cardiology, rheumatology, and so on, will quickly have a staff member providing those value-added PIN services.
• For the most part, because most physicians are locked into local and regional health systems, it will mean more coordinated system self-referral, reducing (optimizing) the patients that “leak” out of a health system to acquire care from another system.
• Training and credentialing programs will arise to meet varying state requirements for non-clinicians to do this work. The cost of that training, licensure, and we can readily assume continuing education will be a cost to practices but a revenue stream for others
• For the truly innovative, the billing units for large physician-based practices can be repurposed, and their assistance in pre-certification of care can be reframed as patient illness navigation, further reducing the costs necessary to collect physician payments.

This is not to say that a Sherpa is unnecessary – they are. But healthcare is a dynamic system and a new regulation will modify its surroundings. We are no longer surprised that a media system optimized for attention is stealing our attention. We should not be surprised that a health system optimized for revenue streams is increasingly expensive.

PIN codes represent a step toward acknowledging and compensating for the often invisible labor of helping patients find and access the care they need. While their introduction signals progress, these codes also highlight the complexity and cost of a healthcare ecosystem that can force patients—especially those with limited resources—to pay for assistance in overcoming barriers that should never have existed. As physicians, care teams, and organizations adapt to these new guidelines, we must remember that true healthcare reform is more than revenue streams or additional billing lines. It’s about improving patient outcomes, ensuring continuity of care, and making our vast and often confusing healthcare system navigable for everyone. By harnessing the spirit of the Sherpa—offering expert guidance and unwavering support—we can help patients achieve healthier outcomes without getting lost along the way.

[1] The need for licensure in the location providing care remains in place.  

Source: New CMS Illness Navigation Codes JAMA Oncology DOI: 10.1001/jamaoncol.2024.6270