Chronic conditions such as Alzheimer’s, arthritis, cancer, COPD, diabetes and hypertension are more common than you may expect, with more than three quarters of Americans aged 65 and older suffering from two or more of these long-term diseases or illnesses.
Chronic conditions come at great expense to both patients and the healthcare system alike. According to a report released earlier this year, these long-term health issues account for 71 percent of healthcare costs.
In an effort to manage these diseases and control costs, the Centers for Medicare & Medicaid Services (CMS) established a process for chronic care management (CCM) designed to improve patients' lives through more frequent interaction with healthcare professionals, while reimbursing providers for their efforts. CCM includes services outside the regular face-to-face appointments, such as care coordination done via email, text or phone, medication management, and 24/7 accessibility.
For healthcare practices, successfully implementing a CCM program can result in reimbursements of $42 or more per patient each month. However, CCM is not being as widely adopted by providers as CMS has hoped. Many primary care physicians see a number of barriers to entry and have even held off implementing CCM processes, including unfamiliarity about what they can bill for and how much time documentation will take, as well as fears surrounding the potential administrative burden on staff members who may already feel overwhelmed with paperwork and patient demands.
With the right plan and tools in place, however, primary care practices — and their patients suffering from chronic conditions — can start to benefit from CCM as part of the shift to value-based care.
Here are five tips your practice can apply to begin taking advantage of CCM opportunities:
• Set up a standard enrollment workflow. If patients are flagged as eligible in their electronic health records (EHRs), healthcare providers should confirm that the patient has two or more eligible chronic conditions, and then recommend participation in the CCM program during an office visit. A patient will only need to provide verbal consent to enroll.
• Develop processes for ongoing implementation. CCM requires providers to schedule monthly outreach outside of office visits, including 20 minutes of care via email, text or phone. This outreach can be done by staff in your office, including the doctor, midwives, nurse specialists, nurse practitioners and physician assistants, as long as they are licensed in the state in which the patient is receiving care. The type of outreach can vary from medication reconciliation and overseeing a patient's self-management of medication to following up after hospital discharges or sharing care plans based on the patient’s comprehensive needs. After each interaction, the provider must review and update the care plan and inform the patient of any changes.
• File claims monthly. Claims for CCM reimbursements should be filed each month. While CCM fee requirements may seem overwhelming and confusing, there are solutions available on the market that can simplify the process and ensure your practice is properly reimbursed for providing enhanced services to patients with chronic conditions.
• Don’t set it and forget it. Like any other new program, it is easy to start off fast but level off or even become neglected as time progresses. Regularly check the temperature of your CCM program to ensure you are consistently enrolling new patients and engaging with your enrolled population in a valuable way.
• Check for commercial payer reimbursement opportunities. While these tips apply to CMS specifically, you should also check with commercial payers to see if they reimburse at higher rates for active management of patients with chronic conditions. Often commercial payers have less stringent requirements and provide 15 to 20 percent higher payments than Medicare.
It’s important to note that CCM does work. Studies conducted by my company have shown marked improvements in patients with diabetes who received care outside in-person appointments. Over time, with more regular engagement with their healthcare providers, these patients experienced reduced glucose and blood pressure levels.
In another study conducted at a Mississippi hospital, patients taking part in CCM programs were half as likely to both be admitted to the hospital and readmitted than the average Medicare recipient. CCM patients’ hospital admissions rates were 12.6 percent, compared to 25.7 percent for the overall Medicare recipient, while readmission rates were 7.7 percent versus 15.2 percent.
If your practice has considered participating in CCM before, now is the time to execute. By applying these five tips, you can significantly increase Medicare reimbursements for a majority of your patients, which will not only help them more effectively manage their conditions, but also benefit the fiscal health of your practice.
About the Author
Zachary Blunt is the manager of population health at Greenway Health, a leading health information technology and services provider. He has worked in the healthcare industry for more than eight years and has been a member of the Greenway team for five years. At Greenway, Zach focuses on the company’s population health and patient engagement tools — he has a passion for improving patient behavior toward their overall health goals. Zach is an MBA candidate in the University of Florida program and received his Health Information Technology and Health Information Exchange Specialist Certificates at the University of Texas at Austin. He currently resides in Tampa, Florida.