In the United States, various chronic diseases are poised to increase, becoming highly prevalent, and worsening over the years, not just for aging baby boomers but among all age groups. At present, 6 out of 10 Americans have at least one chronic disease like heart disease, stroke, cancer, or diabetes according to the Centers for Disease Control and Prevention (CDC). The centers add that chronic diseases are the leading causes of death and disability in the country and also the leading driver of healthcare costs. The burden on the economy is huge and increasingly exacerbated by the devastating effects of the Coronavirus pandemic partially because many Americans are already vulnerable because of their chronic medical conditions. 

This is why the Center for Medicare and Medicaid Services (CMS) is strongly encouraging the employment of Chronic Care Management (CCM) services as an alternative and cost-effective strategy to manage chronic care patients. Introduced in 2015 as a separately paid service under the Medicare fee schedule, CMS has gone full throttle in incentivizing practitioners who participate in CCM programs because it has been proven effective in producing positive health outcomes and reducing health care costs from ER visits to hospitalizations. Yet, after six years, only a few chronic care patients have benefitted from the program. Market penetration is less than 10% of the 40 million who have multiple chronic conditions when more than ⅔ of whom are eligible for CCM. The time has come for practitioners to fully understand what CCM is about and the quantifiable benefits it brings.

Chronic Care Management: Understanding the Basics

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions according to the American College of Physicians (ACP). The covered conditions are extensive and not just limited to diseases but can include autoantibodies, heritable disorders, and mental health issues. To name just a few, CCM can be used to better manage Type 2 Diabetes, Hypertension, Depression, Cancer, Chronic Obstructive Pulmonary Diseases, and Asthma. Also included in the services is the communication and the coordination of care among various providers,

CMS calls it a “care management service,” one of many covered programs that enable a provider to manage and coordinate care in between in-office visits. Incidentally, Remote Patient Monitoring (RPM) is also another example of a care management service. CCM covers the monitoring and evaluation of the health care needs of patients, the development of an evidence-based plan for their care, and the implementation of a multidisciplinary team. The critical components to this approach are monitoring and measuring health status, evaluating the patient’s response to treatment, estimating how long it will take before symptoms are resolved, assessing progress toward recovery, and assessing community resources that may be necessary for treatment.

CCM: An Emerging Strategy in Chronic Care Delivery

At present, CCM is an emerging practice that physicians can utilize to screen for or predict the future need for medical and surgical treatment for their chronic care patients.  The scope of CCM has expanded over the years due to the increase in chronic diseases and the increasing demand for affordable, quality, and appropriate health care.

A comprehensive and extensive electronic health record is one of the most critical elements. It contains information about a patient’s medical conditions, medications, allergies, medical history, demographics, and past providers. Chronically ill patients generally see multiple providers so a detailed electronic record facilitates optimum care coordination. In CCM, a designated member of the patient’s care team maintains a continuous relationship with the patient in between office visits.

The ideal situation would be for patients with long-term conditions to feel supported in reaching their health goals. CCM programs enable patients and designated caregivers to access their health information and care plans 24/7. They can contact the care team at any time of the day or night. Patients’ caregivers can also contact by phone or via a secure patient portal. Since CCM is about the long-term and ongoing management of chronic health conditions, it is also used to describe the ongoing commitment of health care professionals in managing such conditions. 

CCM and Its Benefits

A remote care management program can produce positive results under the right circumstances. In essence, patients receive better care when providers can access a reimbursement-funded care management network. 

Other benefits include:

Continuity of Care

By providing continuous care and managing patients’ conditions, chronic care management is intended to improve the quality of life for patients. This results in decreased pain and stress, increased mobility and fitness, better patterns of sleep and relaxation for a patient. The main objective of CCM is to provide patients with a coordinated and practical approach to their health needs. This is achieved through the combination of screening, testing, education, and intervention.

Access to Care

A large majority of patients visit their providers only when they are sick. CCM emphasizes proactive, preventative care. Care team members proactively contact enrolled Medicare beneficiaries monthly via phone and electronic means. Medicare requires a nurse hotline, as well as preventative services, to be part of CCM services. A program like CCM that combines proactively reaching out for preventive care with extended availability is quite powerful. In addition to reducing emergency room visits and hospitalizations, CCM increases access to care that has been designed to reduce or slow functional decline.

Healthcare Savings

It has been shown that patients enrolled in a CCM program, even with a small monthly coinsurance requirement, enable them to reduce their annual healthcare costs. Preventative care keeps patients healthy and away from the hospitals, and may include finding less-expensive prescription options that can help patients reduce their overall healthcare spending.

Achieving Healthcare Goals

Clinicians who specialize in care management provide patients with the tools to manage chronic conditions on their own. Clinical staff will evaluate each patient’s chronic conditions individually and develop goals to improve health outcomes along with their primary care providers. A comprehensive care plan documents these goals and continually references them during every interaction with the patient.

New Revenues Stream

The Centers for Medicare & Medicaid Services (CMS) recognize the need for physicians to effectively provide chronic care management and in response, have continued to increase the rates for CPT codes to reimburse physicians for preventative medical services. Moreover, by combining direct CCM reimbursement with ancillary revenue from routine office visits and other services throughout the year, just one patient actively engaged in CCM can generate over $500 of extra income per year.