Chronic Care Management Gets Mixed Reviews

Marcia Frellick

August 10, 2017

More than 2 years after Medicare launched its Chronic Care Management (CCM) payment policy, researchers are finding mixed reviews.

The program that began in January 2015 reimburses providers for CCM components that happen outside an office visit, but providers have been slow to get on board, and early uptake was less than 5%.

Findings from a new study published online July 28 in the Journal of General Internal Medicine shed light on what is holding them back.

Ann S. O'Malley, MD, a senior fellow at Mathematica Policy Research in Washington, DC, and colleagues report that during the first 15 months, uptake was 4.5%. Of 224,187 noninstitutional primary care providers that billed Medicare, only 10,022 billed for CCM services.

Researchers conducted semistructured telephone interviews from January to April 2016, with 71 respondents (60 billing and nonbilling providers and staff knowledgeable about their practices' CCM participation and 11 professional society representatives), to find out where they saw strengths and weaknesses of the program.

The interviews occurred with practices of varying sizes, urban vs rural status, ownership type, and specialty. They indicated many plusses, including mostly positive feedback from patients. CCM encourages patients to adhere to treatment, improves access to care team members, and improves continuity of care. Patients like having a specific point of contact, according to the findings.

"Although some providers had initial concerns that CCM might hinder patient–primary care provider continuity (if other specialists billed for CCM services), only one provider had experienced this problem," the researchers write.

Reimbursement for Upfront Costs Falls Short

But interviewers also heard about considerable barriers. Professional society representatives and both billing and nonbilling providers said reimbursement was not enough to cover upfront costs of staffing, particularly those for hiring a care manager, modifying workflow, and the time needed to care for complex patients.

Under CCM payments policy, providers may bill for 20 minutes of clinical staff time once per month per patient for out-of-office care management and coordination.

"Some respondents reported that practice staff usually spent 45 to 60 minutes on each CCM patient each month — and several hours on the most complex patients," the researchers write.

Others said infrastructure problems held back the exchange of health information among providers, and electronic health records were not able to adequately document and update care plans.

To bill, practices must have a certified electronic health record, assign a clinician to each patient, maintain a care plan in collaboration with the patient, communicate with other health professionals, and manage medications.

Potential Is There

Ari Hoffman, MD, from the Department of Medicine at the University of California, San Francisco, writes in a related commentary published August 7 that the program has unrealized potential.

"[W]e know that CCM, done right, can decrease hospitalization and [emergency department] visits over time, with an estimated $101-per-participant reduction in Medicare spending."

He says negatives for providers include substantial documentation and active billing, instead of the automatic per member/per month payments used in patient-centered medical homes. Under CCM, providers must bill for each beneficiary each month that they deliver CCM services.

Negatives for patients include part B coinsurance payments, he notes.

"One in seven Medicare beneficiaries have no supplemental coverage, and they are disproportionately black, poor, and disabled," Dr Hoffman writes. "Not only is the coinsurance ineffective at achieving the goal [of using effective services], but it contributes to health inequity."

He points out that a limitation of the study is that researchers interviewed only four nonbilling providers.

"[T]hese findings suggest that further improvements in the CCM payment policy that reduce barriers to uptake and ensure best practices have the potential to reduce costly utilization, improve outcomes, and save money, the holy grail of healthcare value," Dr Hoffman concludes.

Funding for data collection and analysis was provided under a contract with the Centers for Medicare & Medicaid Services. The authors and Dr Hoffman have disclosed no relevant financial relationships.

J Gen Intern Med. Posted online July 28, 2017. Article full text. Published online August 7, 2017. Commentary full text

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