how to use hit for ccm

PHYTEL | WHITEPAPER

How to Use HIT in Medicare’s Chronic Care Management Program

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com2 Copyright ©2015 Phytel Inc. All rights reserved.

Introduction

Background

CCM Program: The Basics

EHR Limitations

CCM Infrastructure Components

Conclusion

Notes

Contents

Page 3

Page 5

Page 7

Page 10

Page 11

Page 14

Page 15

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com Copyright ©2015 Phytel Inc. All rights reserved. 3

IntroductionFacing a sharp increase in future costs because of demographic trends,1 the Centers for Medicare and Medicaid Services (CMS) is trying to reduce spending on its chronically ill Medicare beneficiaries, who generate most of that program’s expenditures.2

In 2010, more than two-thirds of Medicare patients had multiple chronic conditions, and they accounted for 93% of Medicare spending. Beneficiaries with multiple chronic diseases accounted for almost all Medicare hospital readmissions. And those with six or more chronic conditions generated about half of Medicare costs.3

“Multiple chronic conditions increase the risks for poor outcomes such as mortality and functional limitations as well as the risk of high cost services such as hospitalizations and emergency room visits,” states a CMS report on this issue.4

Primary care physicians deliver the bulk of chronic care. But with the population growing and aging faster than new generalists are being added to the physician workforce,5 doctors are often finding they do not have the time to deliver all the recommended chronic care to patients during office visits. In fact, it has been estimated that to do so would require 10.6 hours a day.6 Moreover, physicians in the fee-for-service Medicare program are being paid mostly for face-to-face office visits, not for the non-visit care that is required to care adequately for people with multiple chronic diseases.

In 2013, CMS took a big step toward reimbursing physicians for non-visit care by launching the Transitional Care Management Program.7 With the introduction of its Chronic Care Management (CCM) program on Jan. 1, 2015, the agency has gone much further in paying for chronic care outside of office visits. The CCM program rewards primary care practices for providing continuous care to the sickest Medicare fee-for-service beneficiaries.8

In essence, the CCM program pays physicians and midlevel practitioners an average of about $42 per patient per month for managing the care of Medicare beneficiaries with two or more chronic conditions. For each eligible patient, practices must perform non-face-to-face care management and care coordination activities for 20 minutes per month and must meet an array of other requirements.9

With the introduction of its Chronic Care Management (CCM) program on Jan. 1, 2015, CMS has gone much further in paying for chronic care outside of office visits. The CCM program rewards primary care practices for providing continuous care to the sickest Medicare fee-for-service beneficiaries.


The potential financial gains are substantial. If

a physician has 150 eligible Medicare patients,

he or she stands to earn more each year from

CCM than from the entire Meaningful Use

EHR incentive program.10

Nevertheless, observers agree that the CCM

regulations will be challenging for the average

practice, partly because the majority of groups

lack the infrastructure they need for CCM.

In fact, Ron Ritchey, the chief medical officer

at eQHealth Solutions, the Medicare quality

improvement organization in Louisiana, told

Healthcare Informatics that physicians should

not view CCM payments as a windfall. Instead,

he said, they should use the money to invest in

the infrastructure needed for patient-centered

medical homes (PCMHs) and to gear up for

value-based reimbursement.11

Health IT is a key part of the infrastructure

that is necessary for both PCMHs and CCM.

For starters, the CCM regulations require

participating physicians to have certified EHRs

that meet the 2011 or the 2014 criteria.12 With

the help of those EHRs, practices are expected

to perform a wide range of functions related to

care management and care coordination.

There is a lot of overlap between CCM

functions and the features of the patient-

centered medical home. Indeed, CMS has

stated that the CCM program is, in part,

a response to the need of PCMHs for

reimbursement of their care coordination

activities outside of office visits.13 So if a

practice meets all of the requirements for

Level 3 PCMH recognition by the National

Committee on Quality Assurance (NCQA),

some observers believe, it should have no

problem in delivering the type of chronic

disease care that CMS mandates.14

But even PCMHs should bear in mind that they

will still be facing these significant challenges:

• Involving patients with the comprehensive

care plans that CMS requires.

• Engaging hospitals and specialists, who are

not currently being paid extra for chronic

care management, to coordinate with

primary care physicians.

• Adapting EHRs that are often not

configured for chronic care management or

non-visit care.

• Automating the routine processes of

chronic care so that the needs of these

sick Medicare patients won’t overwhelm

the practice.

This paper explains what CMS expects

providers to do in exchange for the CCM fees.

In addition, it describes some best practices

for using health IT to support the effort and

maximize the chances of success.

The potential financial gains are substantial. If a physician has 150 eligible Medicare patients, he or she stands to earn more each year from CCM than from the entire Meaningful Use EHR incentive program.


BackgroundChronic diseases generate more than three-quarters of U.S. health spending, and an even higher percentage of Medicare costs. Because the prevalence of these conditions rises with age, chronic diseases have a greater impact on Medicare beneficiaries than on the population as a whole.14

In 2010, 21.4 million Medicare beneficiaries, more than two-thirds of the total, had multiple chronic conditions. The most common conditions were hypertension (58%), high cholesterol (45%), heart disease (31%), arthritis (29%), and diabetes (28%). Other chronic illnesses widespread among Medicare patients included heart failure, chronic kidney disease, depression, COPD, Alzheimer’s disease, atrial fibrillation, cancer, osteoporosis, asthma, and stroke.15

Thirty-two percent of Medicare beneficiaries had two or three chronic conditions, 23% had four or five, and 14% had six or more. Among those with four or more diseases, there was a strong correlation between age and the number of conditions.

More than 60% of patients with six or more conditions were hospitalized in 2010, and those patients accounted for 63% of post-acute care costs. Ninety-two percent of those patients had a doctor visit, and 46% had 13 or more visits. Seventy percent of them had an ER visit, and over a quarter had three or more visits.

On average, CMS spent $9,738 per Medicare beneficiary in 2012. The cost rose steeply with the number of chronic conditions, reaching an average of $32,658 for patients with six or more conditions.16

OLDER ADULTS ARE MORE LIKELY TO HAVE MULTIPLE CHRONIC CONDITIONS

PERCENTAGE OF POPULATION WITH CHRONIC CONDITIONS

6.7%

27%

16.8%

40.3%42.8%

68%73.1%

90.7%

A G E S 0 - 1 9

O N E O R M O R E C H R O N I C C O N D I T I O N S

T W O O R M O R E C H R O N I C C O N D I T I O N S

A G E S 2 0 - 4 4 A G E S 4 5 - 6 4 A G E S 6 5 +0

2 0

4 0

6 0

8 0

1 0 0

Source: Robert Wood Johnson Foundation, www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583


Inadequate care

Patients with multiple chronic conditions use medical goods and services at higher rates than other patients do, and they often receive duplicate tests, drug prescriptions that are contraindicated, and/or conflicting treatment advice.17

This is not surprising in light of the fragmentation of chronic care. More than half of patients with serious chronic conditions have three or more physicians.18 The average number of physicians that a chronically ill Medicare patient sees ranges from four for those who have just one condition to 14 for those with five or more conditions.19 One study explains the situation as follows:

System fragmentation means that chronically ill patients receive episodic care from multiple providers who rarely coordinate the care they deliver. Because of this structural deficiency, patients with chronic illnesses receive only 56 percent of clinically recommended medical care. That gap in care may explain a nontrivial portion of morbidity and excess mortality.20

When patients with multiple chronic conditions do not receive recommended ambulatory care in a coordinated fashion, they are hospitalized more often than they otherwise would be.21 One study of “ambulatory-care sensitive conditions” found that hospitalizations of patients with these chronic diseases rise steeply with the number of conditions: For Medicare beneficiaries with two conditions, there are nine avoidable hospital admissions per 1,000 Medicare beneficiaries; for those with six conditions, the number is 109.22

Considering all of these facts, it is clear that patients with multiple chronic illnesses could benefit—and that the cost of their care would drop—if they received appropriate, coordinated care. The purpose of the CCM program is to encourage primary care physicians to provide this kind of care to Medicare beneficiaries.

It is clear that patients with multiple chronic illnesses could benefit—and that the cost of their care would drop—if they received appropriate, coordinated care. The purpose of the CCM program is to encourage primary care physicians to provide this kind of care to Medicare beneficiaries.


CCM Program: The BasicsUnder the CCM program, eligible providers are paid an average of $41.92 per month for each eligible patient for whom they provide the requisite services.23 Of that amount, CMS pays 80% and the patient pays 20%, or $8.40, as a copayment.

To be eligible for CCM, a patient must be in the Medicare fee-for-service program and have two or more chronic conditions. These conditions must be expected to last for at least 12 months or until the patient dies. They must threaten the patient with the risk of death, acute exacerbation/decompensation, or functional decline.

Physicians and other eligible providers must ask each eligible patient for permission to be their CCM provider. The clinicians must explain what CCM is and receive the patient’s written consent, including authorization for data sharing with other treating providers. The patient must also be informed that only one provider can bill for the CCM services provided to that person in any month.

Primary care physicians, nurse practitioners, and physician assistants can bill for CCM. Specialists who provide the bulk of a patient’s care can also do so, but must meet all of the same requirements as primary care providers.

Any certified healthcare professional, including a certified medical assistant, can provide CCM services. Contracted clinicians, such as covering or locum tenens physicians, can also deliver CCM services as long as they have access to the patient’s electronic record and are under the general supervision of the CCM physician or another designated practitioner.

For this program, CMS has relaxed the rules regarding direct physician supervision of non-physician clinicians. A doctor need not be in the same location as another clinician who is providing CCM services.24-25

Scope of services

CCM services fall roughly into two buckets: non-face-to-face care management and care coordination activities that involve communications with other providers and community agencies. These services have been summarized as follows:

• 24/7 access to care management services

• Continuity of care with a designated practitioner or member of a care team

• Care management, including an assessment of the patient’s medical, functional, and psychosocial needs; preventive care; medication reconciliation; and oversight of the patient’s medication self-management

• Creation of a patient-centered care plan that fits patients’ choices and values

• Management of care transitions, including referrals, follow-up after an ER visit, and follow-up after discharge from a hospital, skilled nursing facility, or other healthcare facility

• Coordination with home- and community-based clinical service providers to meet patients’ psychosocial needs and address their functional deficits

• Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the beneficiary’s care

• Electronic capture and sharing of care plan information.26

To be eligible for CCM, a patient must be in the Medicare fee-for-service program and have two or more chronic conditions. These conditions must be expected to last for at least 12 months or until the patient dies. They must threaten the patient with the risk of death, acute exacerbation/decompensation, or functional decline.


The designated CCM clinician must establish, implement, revise, or monitor and manage an electronic care plan based on an assessment of the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient. The care plan must contain a record of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions, and oversight of patient self-management of medications. It must also include an inventory of clinicians, resources, and supports specific to each patient, including a description of how the services of agencies or specialists unconnected to the designated clinician’s practice will be coordinated.

This care plan must be available to all members of the practice care team at all times. In addition, it must be shared with providers in other practice settings who are caring for the same patient. As we explain later, this requirement will pose a technological challenge to many providers.27

Time-related requirements

To bill for CCM in any given month, the care team of an eligible provider must provide at least 20 minutes per month of non-face-to-face care management and/or care coordination to a patient who has agreed to receive CCM services. Care team members may perform such activities in one block of time or in bits and pieces during the month. They must keep track of the time they spend on that patient and document it in the record.28

Among the activities that count toward the 20-minute total are:

• Phone calls and emails with the patient

• Time spent coordinating care (by phone or other electronic communication, but not fax) with other clinicians, facilities, community resources, and caregivers

• Time spent on prescription management and medication reconciliation.29

Remote patient monitoring, using devices that communicate online with the practice, does not count toward the 20 minutes of CCM services. Providers can include the time they spend reviewing physiologic data from monitoring devices, according to the American Telemedicine Association (ATA). But they cannot bill CMS’ code for that service if they’re doing it as part of their CCM activities.30

Billing rules

CMS also rules out potential billing in duplicative areas. If a provider bills the CCM code (99490) for a particular patient, that provider cannot, in the same month and for the same patient, bill for transitional care management, home health supervision, hospice care supervision, or certain end-stage-renal-disease (ESRD) services. The provider can, however, bill those codes for non-CCM patients to whom he or she provides those services. Office visits by CCM patients can also be billed separately in the same month in which CCM services are delivered to those patients.31

CHRONIC CARE MANAGEMENT PROGRAM

AMONG THE ACTIVITIES THAT COUNT TOWARD THE 20-MINUTE TOTAL ARE:

Phone calls and emails with the patient.

Time spent coordinating care (by phone or other electronic communication, but not fax) with other clinicians, facilities, community resources, and caregivers.

Time spent on prescription management and medication reconciliation.29

To bill for CCM in any given month, the care team of an eligible provider must provide at least 20 minutes per month of non-face-to-face care management and/or care coordination to a patient who has agreed to receive CCM services.


Practices must make sure they have provided 20 minutes of CCM services to each patient within the month for which they’re billing. It is possible that they might not perform these services for 20 minutes for certain patients every month; if so, practices cannot bill for those patients in those months.32

Economic calculation

The economics of CCM are compelling for practices that have a certified EHR and have implemented the necessary workflow changes. Margalit Gur-Arie, a principal of the BizMed consulting firm, has provided one of the best explanations of how much physicians can expect to earn from CCM.33

Based on a payment of $40 per patient per month, she estimates, a single CCM patient can generate $380-$480 per year, depending on whether a practice can collect the $8 copayment.

The average primary care physician has roughly 200 Medicare fee for service patients with multiple chronic conditions, she says. Of those patients, about 150 will probably consent to receiving CCM services. At the rates specified above, those patients will bring in $60,000-$72,000 a year in CCM revenue for each primary care physician.

For those 150 patients, a practice will have to provide at least 50 hours per month of CCM services at 20 minutes per patient. Fifty hours a month is about a third of the time a full-time equivalent employee spends at work in a typical practice. So if the average non-physician clinician on the care team were paid $30,000 a year, the labor expense for CCM would be $10,000 per year, or $67 per patient per year.

Adding in the “setup cost” and other expenses, which Gur-Arie estimates at $5,000, the total cost of providing CCM services would be about $15,000, or $100 per patient per year. That leaves net revenue of $45,000-$57,000 per provider.

Care must be taken, however, in applying these calculations. First, they don’t include the cost of building infrastructure, which can, however, be paid off over time. Second, some physician time will be required to supervise CCM activities and communicate with patients. Third, some non-provider care team members may earn more than $30,000 a year, which would raise the labor cost. And finally, there’s no guarantee that the care management and coordination that any patient needs will be limited to 20 minutes per month. That is why practices must look beyond CMS’ bare bones requirements and figure out how to make their chronic care management as efficient as possible.

ASSUMPTIONS FOR ONE PHYSICIAN:

On average, one physician is responsible for roughly 200 Medicare FFS patients with multiple chronic conditions.

Of those, 150 will most likely consent to participate in the CCM program.

Each of these participating patients will be billed $40/month.

The annual revenue for this group of patients totals $72,000. of potential revenue for

CCM services.

100 physicians that’sAnd if a group had

7,200,000$


EHR Limitations As mentioned earlier, a provider who wishes to bill for CCM must have a 2011 edition or a 2014 edition certified EHR. At a minimum, that EHR must be used for:

• Structured documentation of demographics, problems, medications, and allergies

• Creation and transmittal of electronic care summaries to other providers

• Storage of Medicare beneficiary consent forms

• Documentation that the care plan was given to the beneficiary

• Recording of care coordination activities, including communications with other providers and community agencies.

In addition, practices must use an EHR or some other kind of application to document their list of CCM patients, the CCM protocols for the care team, and the CCM services that were provided, including what they were, who provided them, when they were provided, and how long they took.34

Devising a longitudinal and comprehensive care plan often exceeds the capabilities of current EHRs. Most EHRs confine their care plan documentation to the assessment and plan section of the visit note. They also lack templates for performing wide-ranging patient health assessments. There is no requirement, however, that the care plan must be created in the EHR. After it is built, it can be stored in the EHR as a document.

Similarly, EHRs can lack the robust registry, analytics, and automation functions required for chronic care management. Reports on patients with particular conditions are difficult to program in some EHRs and are rigidly prebuilt in others. Moreover, except for canned health maintenance alerts, the information in these reports is not available at the point of care.

EHRs also are not designed to support the work of care teams. A recent study found that EHRs lack integrated care manager software and are inadequate for tracking patient data over time.35

EHRs may not have good methods of documenting non-visit care or care coordination activities. Phone calls and emails, whether between providers or between providers and patients, can be documented. Some EHRs also allow clinicians to capture non-billable encounters and add some notes. But the systems are not designed to allow care team members who provided CCM services to document most of them, because doctors must enter this information for ordinary fee-for-service billing. Moreover, EHRs don’t provide any way to record the duration of non-visit encounters or care coordination activities.

It’s possible to create Excel spreadsheets outside your EHR for some of these functions. But those spreadsheets cannot identify care gaps, cannot be used to trigger patient outreach, and have limited actionable utility to care managers. In addition, the patient data in the EHR must be transferred manually to these spreadsheets.

For practices that find spreadsheets inadequate, specialized software that interfaces with EHRs and performs most of the CCM functions is available. If they have already implemented the process changes required for PCMH recognition, they might be able to make do with EHR workarounds. Many PCMHs also use ancillary population health management software with their EHRs, and NCQA awards auto-credits for the use of some solutions.

Practices must use an EHR or some other kind of application to document their list of CCM patients, the CCM protocols for the care team, and the CCM services that were provided, including what they were, who provided them, when they were provided, and how long they took


CCM Infrastructure ComponentsThe first step in establishing a process for CCM is to search the practice’s EHR for Medicare patients who have two or more chronic conditions and meet the other criteria. This is easier to do with a standalone patient-centric chronic disease registry, which makes such reports easier to generate. Then the practice must create a log of CCM-eligible patients and must attribute each to a particular physician or other provider.

Next, the practice has to contact these patients so that their physician can discuss the CCM program with them, invite them to participate, and ask them to sign permission forms. If they haven’t had a Medicare-covered well visit in more than a year, they might be asked to come in for that and at the same time discuss the CCM program. Alternatively, they might be approached during their next scheduled follow-up visit or reminded to make an appointment if they’re overdue for recommended care.

The outbound messaging to patients about the need to make appointments can be done automatically with software attached to a patient-centered registry. Otherwise, nurses must call the patients individually or send them letters.

Care Plans

Physicians and clinicians can work with patients to build care plans during visits, but practices should consider asking patients to complete online questionnaires prior to those encounters. For example, practices can use health risk assessments and functional status surveys to collect data on the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient.

Such an approach would save a lot of time for a clinician in a busy primary care practice who is trying to assess the health of 150 patients. It would also be likely to supply more consistent and comprehensive data than interviews alone could elicit.

Once this information has been collected, practices can modify EHR templates or use homegrown forms or software outside their EHR to construct care plans. Ideally, such care plans should be usable by care managers. They should include fields for documenting progress toward patient goals, interventions, and the amount of time spent on CCM services.


Practices that tackle CCM should consider acquiring population health management software to automate their chronic care management processes. Such applications can enable them to quickly scale up to handle, for example, 150 high risk Medicare patients per provider, and they can use the same software to facilitate care management for other patients with chronic conditions.

Information Sharing

Every patient enrolled in CCM must have

access to a copy of his or her care plan. This

can be provided through a patient portal

attached to the EHR. The same portal can be

used to enhance communications between

patients and care teams, including automated

reminders about preventive and chronic care.

Care team members must have online access

to the care plan 24/7. That is not a huge

challenge if they are all using the same EHR.

But, depending on how the system has set up

its security protocols, it might be more or less

difficult for a clinician to log into the system

from home or some other location.

A more complex challenge is posed by the

requirement that outside providers who care

for the patient have access to the care plan.

The CCM provider can use Direct messaging

or some other secure messaging system to

convey the plan to those providers, probably

as part of a referral; but it will have to be in

the form of a text document or PDF, which

not all EHRs accept as attachments to Direct

messages.

Moreover, the CCM provider must be aware

of who else is caring for the patient and must

know their Direct address. And the designated

provider must ensure that outside clinicians

see the plan whenever it is updated.

Care summaries must also be exchanged with

other providers to support care coordination.

Certified EHRs can generate a structured care

summary document called a CCDA, but the

lack of interoperability between EHRs and the

slow development of Direct messaging still

impede the exchange of CCDAs.

Most EHRs include referral modules, and

Direct messaging is often part of those

modules in the latest upgrades. But most

EHRs don’t track whether patients made

appointments with the specialists or whether

those consultants sent reports back to the

referring physicians. So practices must set up

a workflow to monitor referrals to and reports

from specialists. High performing PCMH

practices will already have these processes in

place, and CCM is poised to leverage them.

Transitional care management

Follow-up with patients after they have been

discharged from a hospital or an ER is a key

component of CCM. The biggest challenge

here is not technological; it’s getting hospitals

to send discharge summaries on a timely basis

and to inform physicians when their patients

have been admitted or have visited the ER.

A recent study shows that this is still a major

problem for many doctors.36

Hospitals can facilitate transitions of care

by using the same EHRs that primary care

doctors do, and this is one reason why so many

healthcare organizations favor integrated

systems. But even if these organizations have

their employed physicians on the same EHR

as the hospital, they still may not be able to

communicate online with community doctors.

The challenge is even greater where post-

acute-care providers are concerned. Nursing

homes and home health agencies have partially

computerized, but most of the systems they

use are not interfaced with inpatient or

ambulatory EHRs. So these communications

will continue to rely on phone and fax.

Despite these barriers, CCM providers must

try to obtain as much of this transition of care

information as they can. If they know when a

patient has been admitted and do not round in

the hospital, they should have some method of

flagging the patient’s admission in their EHR

and finding out when they’ve been discharged.

They also need to reach out to patients to

find out whether they understand their

discharge instructions and to remind them to

make appointments to see their primary care

doctors. Software is available to automate both

of the latter functions.


Automation of care management

Care management is a very labor-intensive

function, even if it is limited to patients with

multiple chronic conditions. In the financial

scenario cited earlier, only a third of an FTE

clinician’s time was required to meet the CCM

requirements of 20 minutes per patient per

month. Spread over several people, that might

seem like a fairly small time investment. But

if a CCM patient has an exacerbation or one

of their conditions is out of control, those 20

minutes could easily balloon into hours.

Moreover, physicians find it difficult to

compartmentalize a treatment approach by

limiting it to patients with a particular type of

insurance. Once they change their mindset and

their office workflow to accommodate CCM,

they’re likely to extend the same approach to

other patients with chronic conditions.

For this reason practices that tackle CCM

should consider acquiring population health

management software to automate their

chronic care management processes. Such

applications can enable them to quickly scale

up to handle 150 high risk Medicare patients

per provider, and they can use the same

software to facilitate care management for

other patients with chronic conditions.

This kind of automation can help practices

identify and manage high-risk patients and

can enable care managers to handle far more

patients than they can with manual processes.

As a result, the practices can meet CCM

requirements with fewer FTEs while ensuring

that patients who need care don’t fall through

the cracks.

Routine functions

Automation can’t be used to build care

plans, and it can’t substitute for one-to-one

interactions between care team members and

patients. But automation and analytic software

can perform many routine functions that

would otherwise take up enormous amounts

of staff time.

Practices can use this kind of software to

identify high-risk patients, detect their care

gaps, and suggest specific interventions to

care managers. This type of program must be

supplied with a wide range of clinical protocols

to cover all of the possible situations that care

managers might encounter.

Within a CCM population are patients who

need very different kinds of care, some

more urgently than others. The needs of a

patient with cancer or Alzheimer’s disease,

for example, are very different than those of

people who have diabetes or hypertension.

And the comorbidities that patients with

multiple chronic diseases have are also very

different, requiring different treatment and

self-care strategies.

To support care management, registry-

linked applications can send patients online

educational materials tailored to each patient’s

unique set of conditions. Care managers can

use analytic software to decide which of their

patients need the most help and coach them

intensively to improve their understanding

of their conditions and how to manage them.

Self-management of medications—one of the

specific requirements of CCM—can especially

benefit from this approach.

Automated campaigns can also be created to

help patients who have specific comorbidities

manage their own conditions better. Although

the time spent programming these online

interventions can’t be counted as part of

the required 20 minutes of CCM activities,

they can prepare CCM patients for their

interactions with care managers and providers.

Automation can help practices identify and manage high-risk patients and can enable care managers to handle far more patients than they can with manual processes. As a result, the practices can meet CCM requirements with fewer FTEs while ensuring that patients who need care don’t fall through the cracks.


ConclusionMedicare’s CCM program is a great opportunity for primary care practices that are already providing extensive care coordination as patient-centered medical homes. While some commercial payers have been giving care coordination fees or other incentives to PCMHs, CCM offers the most substantial and sustainable reward to PCMHs and other primary care providers for what many of them have been doing for free or with term-limited grant subsidies up to now.

The financial incentive in the CCM program is substantial, but it requires an investment in infrastructure and a

commitment to change that many practices will find daunting. If a group hasn’t formed a PCMH, it will have to build

care teams and train them to focus on chronic care, both during and between visits. A great deal of bridge building

with hospitals, specialists, and post-acute-care providers will be required. And the practice will have to change

its work processes to become more patient centered and to accommodate the requirements of the information

technology it is putting in place.

Obviously, large groups have more resources to meet these challenges than small ones do. But small and medium

sized groups can take advantage of CCM, too, especially if they’re willing to do the work to achieve NCQA

recognition as a medical home. In either case, practices would be well advised to consider using ancillary software

designed for population health management.

The potential benefits of CCM go far beyond the direct payments from Medicare. Engaging in this program could

prepare practices to participate in alternative payment models and value-based reimbursement. They could apply

the same health IT and workflows they use for CCM to all of their chronically ill patients. And in the end, seizing

this opportunity can pay off in spades for the patients who will get the care they need to become healthier, avoid

unnecessary services, and enjoy a better quality of life.

The potential benefits of CCM go far beyond the direct payments from Medicare. Engaging in this program could prepare practices to participate in alternative payment models and value-based reimbursement.


1. David Blumenthal, Karen Davis, and Stuart Guterman, “Medicare at 50—Moving Forward,” NEJM, Jan. 28, 2015 DOI: 10.1056/NEJMhpr1414856.

2. Mark Hagland, “Medicare’s New Chronic Care Management Codes for MDs: Clinical IT and Other Requirements,” Healthcare Informatics, Jan. 14, 2015.

3. Centers for Medicare and Medicaid Services (CMS), “Chronic Conditions Among Medicare Beneficiaries: 2012 Chartbook,” http://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf.

4. Ibid.

5. Stephen M. Petterson, Winston R. Liaw, Robert L. Phillips, David L. Rabin, David S. Meyers, and Andrew W. Bazemore, “Projecting US Primary Care Physician Workforce Needs: 2010-2025,” Annals of Family Medicine 2012;10:503-509.

6. Thomas Bodenheimer, “Coordinating Care—a Perilous Journey Through the Health Care System,” NEJM 358, no. 10 (2008); 1064-1071.

7. CMS, “Transitional Care Management Services,” http://cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact- Sheet-ICN908628.pdf

8. CMS Fact Sheet: “Proposed policy and payment changes to the Medicare Physician Fee Schedule for Calendar Year 2015,” July 3, 2014, http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact- sheets/2014-Fact-sheets-items/2014-07-03-1.html

9. Ibid.

10. BizMed webinar, “Chronic Care Management,” https://www.bizmedtoolbox.com/Documentation/ Library/5/2015013011333871820150130113338718Default.pdf

11. Hagland, “Medicare’s New Chronic Care Management Codes.”

12. CMS, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014,” Federal Register, Dec. 10, 2013, https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to- payment-policies-under-the-physician-fee-schedule-clinical-laboratory#h-310

13. CMS, “Revisions to Payment Policies Under the Medicare Physician Fee Schedule.”

14. BizMed webinar

15. Robert Wood Johnson Foundation and Johns Hopkins Bloomberg School of Public Health, “Chronic Care: Making the Case for Ongoing Care,”2010, http://www.rwjf.org/content/dam/farm/ reports/reports/2010/rwjf54583

16. CMS, “Chronic Conditions Among Medicare Beneficiaries: 2012 Chartbook.”

17. RWJF and Bloomberg, “Chronic Care: Making the Case for Ongoing Care.”

18. Ibid.

19. Vogeli C, Shields AE, Lee TA, et. al. Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs. J Gen Intern Med. 2007 December; 22(Suppl 3): 391–395. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598/

Notes


20. Thorpe KE, Ogden LL, Galactionova K. Chronic Conditions Account For Rise In Medicare Spending From 1987 to 2006. Health Aff April 2010 vol. 29 no. 4 718-724. http://content.healthaffairs.org/ content/29/4/718.full

21. RWJF and Bloomberg, “Chronic Care: Making the Case for Ongoing Care.”

22. Ibid.

23. CMS Fact Sheet

24. Kent Moore, “Chronic Care Management and Other New CPT Codes,” Family Practice Management. 2015 Jan-Feb;22(1):7-12.

25. AMGA , “Medicare Physician Fee Schedule Proposed Rule for Calendar Year 2015: Summary of Key Provisions,” http://www.amga.org/wcm/Advocacy/Issues/RegAffs/2015FeeScheduleSummary. pdf?WebsiteKey=366827a3-43b6-40f3-bd5c-703e097b3d0b&hkey=23abec7a-e4bb-40e6-8e64- 4760e2903395&=404%3bhttp%3a%2f%2fwww.amga.org%3a80%2fwcm%2fADV%2fCMS%2fwcm% 2fAdvocacy%2fIssues%2fRegAffs%2f2015FeeScheduleSummary.pdf

26. Moore and AMGA

27. American College of Physicians, “Chronic Care Management Tool Kit: What Practices Need to Do to Implement and Bill CCM Codes,” https://www.acponline.org/running_practice/payment_coding/ medicare/chronic_care_management_toolkit.pdf

28. Ibid.

29. Ibid.

30. American Telemedicine Association, “Update on CMS Payment Decisions – Two Steps Forward, One Back,” http://www.americantelemed.org/news-landing/2014/11/07/update-on-cms-payment-decisions- --two-steps-forward-one-back#.VNEXGCmKJ4V

31. ACP, “Chronic Care Management Tool Kit.”

32. PYA white paper, “Providing and Billing Medicare for Chronic Care: Updated to Include 2015 Proposed Medicare Physician Fee Schedule,” 2014.

33. BizMed webinar

34. Ibid.

35. Ann S. O’Malley, Kevin Draper, Rebecca Gourevitch, Dori a. Cross, and Sarah Hudson Scholle, “Electronic health records and support for primary care teamwork,” JAMIA. DOI: http://dx.doi. org/10.1093/jamia/ocu029. First published online: 27 January 2015.

36. Chun-Ju Hsiao, Jennifer King, Esther Hing, and Alan E. Simon, “The Role of Health Information Technology in Care Coordination in the United States,” Medical Care, February 2015, 53;2:184-90.

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