In 2015, the Centers for Medicare & Medicaid Services (CMS) began offering monthly reimbursements to providers for chronic-care management (CCM) services not conducted during a face-to-face patient visit.
Why Chronic Care?
Chronic conditions are the most common health problem in the United States, particularly among Medicare beneficiaries. Medicare has defined fifteen chronic conditions that are common among its beneficiaries, listed below. These conditions, as well as others, and their related care, are the focus of the CMS CCM initiative.
In the most recent report from CMS, the percentage of Medicare FFS beneficiaries with the 15 selected chronic conditions is as follows:
- High blood pressure: 58%
- High cholesterol: 45%
- Ischemic heart disease: 31%
- Arthritis: 29%
- Diabetes: 28%
- Heart failure:16%
- Chronic kidney disease: 15%
- Depression: 14%
- COPD: 12%
- Alzheimer’s disease: 11%
- Atrial fibrillation: 8%
- Cancer: 8%
- Osteoporosis: 7%
- Asthma: 5%
- Stroke: 4%
Centers for Medicare & Medicaid Services, 2012
Patients with chronic conditions experience hospitalization rates that increase respectively with the number of their chronic conditions. Beneficiaries with chronic conditions account for 90% of Medicare expenditures. Overall, 86% of national health spending and 99% of Medicare spending is for care of chronic conditions and diseases. In addition to CMS, patients also bear the burden of these enormous costs in the form of out-of-pocket costs, including copayments, deductibles, non-covered services, and monthly premiums.
In addition to financial strain, patients dealing with chronic conditions face quality of life issues as a result of their diseases. Increased pain, as well as diminished physical, social and mental health may all be affected by chronic illness. Chronic conditions and their complications are in many cases preventable, but poor lifestyle behaviors, including lack of physical activity, poor nutrition, tobacco use, and drinking too much alcohol, can exacerbate conditions (CDC, 2015). Most of the causes of the top 10 causes of death among older adults are due to chronic disease (Heron, 2015).
Goals of Chronic Care Management
The overarching priority of any CCM program is to improve care and outcomes for those with chronic illness. Tackling overall care for someone with a chronic condition, or a constellation of chronic conditions, will improve the quality of life of the individual, decrease their individual financial burden in terms of medical costs, and ultimately lead to a healthier, longer life.
For providers, CCM is a tool that helps them better manage their patients’ chronic health conditions, increase patient satisfaction and communication, and also realize reimbursement for these services. For Medicare, in addition to the altruistic goal of helping their patient population lead healthier lives, there is also enormous savings to be realized by more effective management of chronic conditions.
The CMS CCM Program
In 2015, in order to incentivize chronic care management, Medicare began paying separately for CCM services provided to their patients. Non-complex CCM services, under the CPT code 99490, are defined as:
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional*, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
- Comprehensive care plan established, implemented, revised, or monitored
*Assumes 15 minutes of work by the billing practitioner per month.
Centers for Medicare & Medicaid Services, 2016
More specifically, CCM services may include:
- At least 20 minutes per patient, per month of chronic care management services
- Personalized help from a dedicated health care professional who will work with the patient to create a care plan based on the patient’s needs and goals
- Care coordination between primary care physicians, pharmacies, specialists, testing centers, hospitals, and other services
- Phone check-ins between visits to keep the patient on track
- Emergency access to a health care professional, 24 hours a day, 7 days a week
- Expert help with setting and meeting the patient’s health goals
Centers for Medicare & Medicaid Services, 2017
Complex CCM services are billed separately and have still more stringent requirements.
In addition to incentivizing providers to offer CCM if they don’t currently offer it, the CCM program is, in effect, allowing providers who already offer these services to finally be paid for their time.
Why aren’t more physicians participating?
If CCM can truly deliver on its promises of healthier patients and increased practice revenue, why aren’t more providers doing it? Typically, we encounter one of the following reasons:
- The practice IS doing CCM, but can only commit limited staffing/time to it and isn’t realizing its potential in terms of either patients reached or quality of care.
- The practice doesn’t have the staff needed to offer CCM. The practice doesn’t have the physical space in their office to provide CCM.
- The practice doesn’t have the additional management bandwidth needed to implement and oversee CCM.
How can we help?
BlueFish’s experienced team enables practices to offer CCM programs that tangibly improve outcomes. Our services, provided for the most part via phone by BlueFish staff, allow patients to have extensive interaction with a nurse and enhance their quality of care. BlueFish client practices have already seen a reduction in patients’ days in the hospital and fewer ER visits. We lift the burden of providing CCM from practices by providing end-to-end service, including patient sign-up, care plan creation, care provided by our nursing staff, and finally, billing.
By managing a practice’s CCM services, BlueFish is freeing up providers to focus on face-to-face encounters, while also realizing reimbursements for non face-to-face visits to which they no longer have to dedicate their time. In our experience, providers can expect to net around $36 per patient per month for CCM services. If a practice has 1,000 patients in their CCM program, the program could realize a reimbursement of $36,000/month, or $432,000/year. BlueFish earns a percentage of the reimbursement, and the practice gains the dual benefit of an improvement in the health of their patient population and revenue that it would not otherwise have generated.
In summary, the CMS CCM program has tremendous potential to improve the quality of life, health and longevity of Medicare patients with chronic conditions. Providers benefit from the ability to provide improved patient care, as well as realize reimbursements for services they either currently provide but do not bill for, or do not have the bandwidth to provide at all. CMS itself benefits by moving closer to its goal of improved outcomes for its Medicare population, as well as realizing enormous cost savings through better management of chronic conditions. Based on the success of these services in our client practices, it’s clear to us that the modest investment from the government in the form of the CCM program is bearing fruit for everyone.
To request more information about how BlueFish Medical can introduce a successful CCM program to your practice, please fill out the form below.
Sources:
Centers for Medicare & Medicaid Services. (2012). Chronic Conditions Among Medicaid Beneficiaries. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf
Centers for Disease Control and Prevention. (2015). Chronic disease overview. Retrieved from http://www.cdc.gov/chronicdisease/overview/
Heron, M. (2015). Deaths: leading causes for 2012. National Vital Statistics Reports, 64(10). U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_10.pdf
Centers for Medicare & Medicaid Services. (2016). Chronic Care Management Services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
Centers for Medicare & Medicaid Services. (2017). Chronic Care Management Services. Retrieved from https://www.medicare.gov/coverage/chronic-care-management-services.html