The Pros and Cons of the Chronic Care Management Program

"To write the program off saying it is too complicated or not worth it may be short-sighted," Dr Shapiro concluded. "Almost anything that is incrementally beneficial to the practice financially becomes important in an era where there is pressure on declining reimbursement."

When nephrologist Michael Shapiro, MD, first heard about the Chronic Care Management (CCM) program run by the Centers for Medicare and Medicaid Services (CMS), he was excited for the opportunity.1  Arthritic conditions, including rheumatoid arthritis and osteoarthritis, are eligible chronic conditions per the CMS definitions. “But when you look at the details, it becomes a little less attractive,” Dr Shapiro said. “In our practice, we decided it wasn’t applicable.”

Through the program, CMS pays $42 per month for physicians to manage the care of patients with 2 or more chronic conditions expected to last at least a year. To receive the payment, providers are required to spend 20 minutes of staff time and create a management plan that is regularly updated.

Here are some of the major issues and points to note about the program.

Signing on

Getting patients to sign onto the program and agreeing to their financial responsibility are major impediments for many specialists.

“The consent issue drives people crazy,” said Martie Ross, principal at Pershing, Yoakley & Associates (PYA). “It is clunky and there is no other service where people have to have a specific signed consent form, so it calls it out as different to patients and creates confusion.”

Patients also aren’t excited about being financially responsible for 20% of the $42 monthly fee. Many patients don’t like paying when there is no face-to-face contact with a provider, Dr Shapiro said. They also feel that much of this care management is “part and parcel” of what physicians should be doing already.

“It is not impossible, but it can be tricky to get this in writing,” Dr Shapiro said.

Overstepping boundaries

In theory, CCM should be a great option for many specialists who often spend a lot of time coordinating patient care. In reality, however, Dr Shapiro said many providers have foregone the program because the role has gone to family practitioners. The CCM program allows for only 1 doctor to bill for a patient each month. Patients in medical home or accountable care organizations, or in groups like Kaiser, are likely receiving the service there.

“If we get [the consent form] in first, we may be upsetting the apple cart,” he said.

According to PYA, the gross revenue of the CCM program for a physician with 1,742 patients could range from $44000 if about one-third of the Medicare patients are eligible to as much as $178 000, if two-thirds are. 

Outside help

If you are hesitant to try CCM because of the time the program might take, Ms Ross said that really should not be a factor. There is a growing market for what she calls “rent-a-nurse” organizations that help with CCM services.

Groups like Renova and Hello Health provide back-office administration, scheduling, billing, clinical documentation, and patient enrollment. With this arrangement, the doctor keeps a portion of the revenue and gives the remainder to the vendor.

Building a system

Creating a system to work the CCM into is among the biggest challenges of the program. But providers should not fear the process. It is similar to setting up a new electronic medical record (EMR). A care plan detailing the patient’s health issues, treatment, social services and medications has to be created and updated regularly. Basic templates are available online that offer documentation logs, patient letters, consent forms and care plans logs.

Dr Shapiro noted it will be important to make sure you know where the documentation will be kept for the 20-minute visits. A checklist should be put together with a list of patients taking part, and who will be in charge of their care. Staff members taking part in the program are an important component. Clinical staff should be gathering information and making patient contact between visits, he added.

“Optimally the physician is doing something else and may have weekly or daily briefings with the team,” he said. “You are not looking at reducing care, but enhancing and improving it.”

Greater opportunity

This type of program is also becoming increasingly prevalent with commercial payers, making CCM a great pilot program you can use to show other payers you can get results.

“You can go to commercial payers and say: ‘we manage these patients already and here are our results … why don’t you choose us as provider of choice and re-negotiate your contract for an episode-based care package’,” Dr Shapiro said.  

After its first year, CMS was apparently “underwhelmed” with the uptake of CCM among physicians, Ms Ross said. Because of this, they made changes in the physician fee schedule for next year that could eliminate the written consent and much of the EMR requirements. They also may be making changes to the initial visit and have proposed a new code for complex chronic care, which would take an hour rather than 20 minutes and reimburse at a higher rate, she said. 

“To write the program off saying it is too complicated or not worth it may be short-sighted,” Dr Shapiro concluded. “Almost anything that is incrementally beneficial to the practice financially becomes important in an era where there is pressure on declining reimbursement.”

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  1. US Department of Health and Human Services Centers for Medicare & Medicaid Services. Chronic Care Management Services ICN 909188. Available at: Accessed September 28, 2016. 

This article originally appeared on Rheumatology Advisor