An Ideal Scenario for Chronic Care Management

January 9, 2018

Thanks to a relatively new CMS program, Medicare recipients with multiple chronic conditions now represent a huge and largely untapped market for healthcare providers. But navigating one’s way through the Chronic Care Management program (CCM) and taking advantage of the potential windall it offers can be challenging.

Under the program, caregivers who provide non-face-to-face monthly consultations with these patients can bill CMS for their services. For CMS, the motivation is obvious. Care management plans and monitored compliance can help prevent common and extremely costly complications. Currently, patients with chronic conditions account for 99% of all Medicare spending, says CMS, and for 84% of national healthcare spending overall. Clearly, if conditions such as diabetes and arthritis, are better managed, there are billions in potential savings to the system.

The number of patients who qualify under the program — already staggeringly high — is also going to grow significantly. As of 2015, Medicare was covering 55.3 million people, roughly two-thirds of whom had two or more chronic conditions. As millions upon millions of Baby Boomers enter their Medicare years, CMS expects the total number of beneficiaries to reach 80 million.

Recent expansion
Providers who are positioned to take advantage of the program can also benefit from a recent expansion. CMS recently supplemented the original reimbursement level (around $43 for a 20-minute consultation) with additional codes, acknowledging that some chronic-care patients require more time for care coordination and more complex medical decision-making than were covered initially. The code for more complex management is reimbursed at about $94 for 60 minutes and at about $47 for each additional 30 minutes.

But overall participation remains minimal. By the end of 2016, the number of chronic-care claims for beneficiaries had reached only about 500,000, suggesting that more than 98% of potential CCM patients were not being reached under the program.

Overcoming the gap
Aside from the relative newness of the program, several factors appear to have contributed to the slow adoption. Chief among them is likely the fact that building an effective CCM program takes time, commitment, and education.

The potential is there, but compliance with CMS guidelines is essential, and a given practice may need upgraded technology and additional staff to provide accurate documentation, submit invoices, capture all available revenue, control costs and manage all other related tasks.

Caregivers may also have to overcome resistance from patients who, in some cases, will be asked to pay a nominal fee for case management they previously got for free. Under the program, patients are responsible for a 20% copay (usually about $8 for a 20-minute consultation).

Nor has the program been especially well publicized, leaving an information gap that providers must overcome. Not surprisingly, some providers have found it difficult to convey the potential value to prospective patients.

The CareThrough solution
The bottom line, says CMS, is that physicians who aren’t participating are leaving hundreds of millions, or even billions, of federally funded dollars on the table. The significance of those unclaimed dollars is underscored by survey findings showing that patients who received CCM care are overwhelmingly positive in their assessments. Nearly 90% say they’re satisfied or very satisfied with both the program and their providers, and 60% say their health has improved as a result of the program.

CareThrough creates a win-win scenario by helping providers reach the millions of patients who can benefit greatly from chronic care management, and, in the process, by substantially increasing revenue for providers. By embedding expert navigators into practices to work side-by-side with care teams, CareThrough frees up physicians to practice what they do best, instead of getting bogged down in the tedium of task management.

By leveraging technology, CareThrough’s navigators help coordinate care and proactively reach at-risk patients. They schedule appointments, monitor adherence and quickly provide physicians and patients with critical information.

Navigators can also connect patients with proper local resources and facilities, make sure labs and other critical needs are met, and offer ongoing expert assistance to help patients self-manage their chronic conditions. The result is that patients not only receive comprehensive care plans, they get the support they need to produce lasting results, and physicians are rightfully rewarded for the role they play in improving the health of a highly vulnerable population.