How to Evaluate a Chronic Care Management Program for Your Practice

With chronic conditions on the rise and Medicare beneficiaries projected to grow significantly in the coming years, practices are turning to Chronic Care Management programs to improve patient outcomes and increase practice revenue. Here's how your practice can evaluate a CCM program and decide whether to implement CCM.

It is predicted that the number of people in the United States with one or more chronic conditions is expected to grow from 141 million in 2010 to 171 million by 2030, which means that almost 1 in 2 Americans will suffer from a chronic disease in the not-so-distant future. In addition to a growing number of patients with chronic conditions, CMS statistics suggest that by 2030, total beneficiaries will be nearly 80 million in comparison to the 55.3 million people as of 2015 when the CCM code 99290 became available.

But before a practice makes the decision to implement a CCM program, it's important to evaluate and understand the benefits and barriers to successful Chronic Care Management. 


What is Chronic Care Management?

In 2015, Medicare launched Chronic Care Management as part of the Connected Care initiative. Chronic care management is, according to CMS, care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.

Chronic care management services may include:

  • At least 20 minutes a month of CCM services
  • Personalized assistance from a dedicated health care professional who works with patients to create a care plan
  • Coordination of care between the patient's pharmacy, specialists, testing centers, hospitals, and more
  • 24/7 emergency access to a health care professional
  • Expert assistance with setting and meeting patient health goals


What are the Benefits of Chronic Care Management?

Care Management delivers a number of benefits to patients by addressing the challenges that exist when a patient has multiple chronic conditions. With CCM, patients can streamline care, avoid duplicate testing, reduce healthcare costs, and enhance the patient's self-management skills.

For practices, CCM can bring in a new stream of revenue, improve patient engagement, and be an attractive differentiator compared to other practices not offering Chronic Care Management. According to a Quest Diagnostics survey, "Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions" physicians see a need for CCM with over 90% of physicians wishing they had help ensuring multiple chronic conditions (MCC) patients were adhering to their care plans and 85% stating they lacked the time to provide adequate care for MCC patients.


Is Chronic Care Management Profitable?

Improving the quality of care is a high priority for CMS, and it's no wonder. Chronic conditions like cancer, arthritis, diabetes, and hypertension are associated with 71% of healthcare costs, according to the Quest Diagnostics survey.

As healthcare reimbursement continues to shift to more value-based reimbursement models, hospitals and physician practices are focusing on ways to improve the quality of care while also containing costs. Offering CCM services can be a financially smart decision for most practices, considering the revenue potential. CCM reimburses physicians under CPT code 99490 for providing non-face-to-face coordination services to eligible Medicare patients with two or more chronic conditions at an average of $40 per enrolled patient per month. 

Every provider and practice will see different revenue results depending on factors like the percentage of Medicare beneficiaries that make up a provider's patient population and the number of patients that consent to participate. Becker's Hospital Review answers the question "how much revenue could an average physician group generate under CCM," demonstrating how one provider can achieve an additional $139,104 in revenue per year through the Chronic Care Management program. 


Should I Outsource Chronic Care Management?

While the financial incentive is substantial, CCM requires an investment in technology and infrastructure in order to achieve the desired results. A recent Porter Research survey states that 88% of practices are trying to manage the CCM program themselves, using only their EHR system and current resources. However, outsourcing or co-sourcing CCM can help practices take a crawl, walk, run approach to value-based care.

Some practices avoid CCM entirely because of the time and costs associated with the program. Outsourcing or co-sourcing CCM has proven to be an attractive alternative in some cases because outsourcing provides practices with the staffing resources and expertise necessary to maximize productivity, earning potential, and avoid the additional personnel costs.


What are the common barriers to a successful CCM program?

Successful CCM has many components, which means that while implementing a CCM program, you should be prepared to face a few challenges. Quest Diagnostics polled 801 primary care physicians and patients over 65 with MCCs to determine some of the top CCM challenges and found that gaining patient buy-in, medical coding, and the overall value outweighing the difficulties of implementing a CCM program are some of the top barriers to success.


  • Gaining Patient Buy-In 

MCC patients surveyed said they were largely satisfied with the care provided at their primary care physician office, with 92% reporting they were getting all the attention they needed at their PCP. However, only 9% of physicians said their MCC patients were getting the care and attention they needed. Because of this, gaining buy-in from patients may be a significant challenge. Practices will need a solid method to market and communicate the program and its benefits to eligible patients. 

  • Accurate Medical Coding and Billing

Because CCM introduces new medical coding guidelines, physicians will need to be well versed in how the CCM program operates and the new codes. Only 51% of physicians surveyed knew that the Centers for Medicare & Medicaid Services pay separately for CCM under the Physicians Fee Schedule for qualified patients with MCCs.

  • Calculate and Demonstrate the Value of CCM 

77% of the physicians said they had not implemented CCM, with 43% citing complicated coding, 37% citing burdensome paperwork, and 25% citing low Medicare reimbursement. There will be a learning curve when implementing a Chronic Care Management program, but gaining physician buy-in can make all the difference. Communicating the value of the CCM program early on, calculating the potential revenue benefits, and sharing patient success stories throughout the program can maintain the positive momentum you'll need to create a successful CCM program.

  • IT Infrastructure

Some practices may already have the communication and CCM features available in their EHR software, while others may require additional technology to support these elements of CCM. Practices that don't already have the IT infrastructure in place to support CCM might benefit from co-sourcing or outsourcing, depending on the budget available and necessary to build the necessary infrastructure.


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