According to AHRQ’s Multiple Chronic Condition Chartbook, 86% of U.S. healthcare spending was for patients with one or more chronic conditions in 2010.  In an effort to curb this spending at the federal level, CMS began reimbursing providers for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions under (CPT) code 99490 on January first 2015. This became known as Chronic Condition Management (CCM) Services. With CPT 99490, providers are paid around $42/month to manage the care of patients with 2 or more chronic conditions expected to last at least a year. Providers must spend 20 minutes of staff time per month on each enrolled patient plus create and maintain a care management plan.

The announcement was met enthusiastically by health IT vendors and providers who believed the code could be worth $17 Billion annually. Twenty months later, the healthcare industry is still figuring things out and the first year response was underwhelming. According to Politico, only 275,000 Medicare patients received the service in 2015 at a cost of $37 Million.

CCM is still promising

Despite the slow start, there’s still a lot of potential for CCM to take off.  This Pershing, Yoakley & Associates (PYA) whitepaper estimates that the gross revenue of the CCM program for a physician with 1,742 patients could range from $44,000 to $178,000 annually depending on how many patients they can enroll .  Better yet, McKesson calculates the ROI at 56 percent, meaning for every dollar a practice spends operating a chronic care program it would get back $1.56. That makes a very strong case for provider groups to figure this thing out.

What are the hurdles to implementing a CCM program?

The most commonly cited hurdles are:

  • Patient Enrollment – Getting patients to sign onto the program and agree to their financial responsibility are major impediments. There’s an extra consent form that causes confusion and patients are responsible for up to 20%, of the cost or about $100/year.
  • EHR Requirements – The program required providers to have 24 x 7 access to their patient records and to use certified EHRs to share clinical care summaries when moving patients from one provider to another.
  • Building processes and systems – The model requires new processes and IT tools to be integrated into the practice. Always a challenge for time and cash-strapped primary practices.

CMS Iterates

Just last month CMS relaxed the CCM standards and dropped the two burdensome EMR requirements mentioned above. According to CMS:

“We are concerned that imposing EHR-related requirements at the service level as a condition of…payment could distort the relative valuation of services priced under the fee schedule …[W]e recognize that other CMS initiatives may be better mechanisms to incentivize increased interoperability of health information systems than conditions of payment assigned to particular services under the [physician fee schedule].”

In addition, CMS is expanding its approach to CCM by incorporating many of the same principles in the upcoming Comprehensive Primary Care Plus (CPC+) model. CPC+ is an Alternative Payment Model (APM) which begins on January 1, 2017. They’ve also cleared hurdles that will allow CPC+ physicians to participate in ACOs which creates the opportunity to re-use some of the CCM architecture that’s already been put in place.

Help is out there

There are plenty of consultants and Health IT vendors building solutions for CCM. Some provide the process and systems to allow practices to keep the care in house (like our #hcbiz guest this week ChronicCareIQ) and others offer a turnkey solution that includes outsourcing the nurses needed to carry out the work.  The point is, there’s no need for practices to go it alone.


#hcbiz 25 Discussion Details

On Wednesday, August 10th the Business of Healthcare community will discuss the Chronic Care Management (CCM) w/ ChronicCareIQ.. We’ll dig in to understand how providers can take advantage of the many CCM opportunities, what support is out there for them and how CCM plays into the CPC+ and ACO models.

12:00 PM EST – Tweetchat

We’ll start with a tweetchat from 12-12:30 PM EST that asks 3 questions in 30 minutes:

Q1: Do you think that providing 20 minutes of non-face-to-face care provides sufficient and meaningful value to patients?

Q2: What are the hurdles to engaging providers and patients in CCM programs? How can they be overcome?

Q3: Can CMS (and private payers) align their many CCM programs so that providers aren’t overwhelmed and can deliver it effectively and profitably?

Follow the #hcbiz hashtag on Twitter or use an app like tchat.io to join the conversation.

12:30 PM EST – The #hcbiz Show! on Blab

This week Shahid Shah and I welcome a few CCM experts to #hcbiz:

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Matt Ethington, CEO, ChronicCareIQ

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Scott Miscovich MD, Windward Primary Care Physicians