What is Chronic Care Management?

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.  A chronic disease or condition is one that lasts for a year or more, requires continuous medical care, or limits daily activities in some way. The term chronic care management refers to any form of medical care provided to patients with chronic illnesses and conditions.

What is Medicare Chronic Care Management (CCM)?

Medicare beneficiaries with multiple chronic conditions (two or more) are generally provided with chronic care management (CCM) services, which are generally non-face-to-face services.

CCM services are crucial elements of primary care that promote better health and reduce overall health care costs, according to the Centers for Medicare & Medicaid Services (CMS).

CCM Coding

CCM services are reported using the following five CPT codes:

• CPT code 99490 – A non-complex CCM is a timed 20-minute service provided by clinical staff to coordinate care across providers and support patient accountability.
• The CPT code 99439 is billed in conjunction with CPT code 99490 for each additional 20 minutes of clinical staff time spent providing non-complex CCM.
• CPT code – 99487 Complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish comprehensive care plans that involve moderate- to high-complexity medical decisions.
• CPT code 99489 A physician or other qualified health care professional must direct each additional 30 minutes of clinical staff time spent providing complex CCM (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490).
• CPT code 99491 – A physician or other qualified health care professional provides at least 30 minutes of CCM services.

What is Chronic Care Management?

Among Medicare beneficiaries with more than one chronic condition, chronic care management (CCM) refers to the chronic care services provided in the United States. In addition to face-to-face visits, patients receive communication and coordination of care related to chronic conditions.

The management of chronic conditions involves a comprehensive care plan that includes:

• Chronic conditions of the patient are documented
• Information about the individual
• Objectives
• Providers of health care
• Prescription drugs
• Other services needed to manage their condition.

A comprehensive care plan describes in detail how a patient’s care will be coordinated.

If a patient has two or more chronic conditions that are expected to last at least a year, Medicare will pay in part or in full for their CCMs.

Understanding Chronic Care Management

In order to qualify for a chronic care management program, a patient must have at least two chronic conditions (such as Alzheimer’s disease, dementia, arthritis, asthma, autism, cancer, heart disease, depression, diabetes, multiple sclerosis, lupus, high blood pressure, hypertension, and/or infectious diseases like HIV/AIDS).

Besides face-to-face patient visits, chronic care management offers services that are non-invasive. The patient’s medical history, medications, allergies, medical history, demographics, and past care providers are included in this comprehensive and comprehensive electronic health record. Chronic disease patients often see multiple care providers; an electronic record facilitating optimal care is essential.

With chronic care management, patients feel supported enough to achieve their health goals by establishing a continuous relationship with a designated member of their care team. In a chronic care management program, patients have 24/7 access to their care plan and health information and may contact their care team at any time. An electronic patient portal or telephone can be used by the patient to contact the caregiver.

Goals of Chronic Care Management

Patients with multiple chronic conditions commonly experience a decreased quality of life. Chronic care management seeks to correct this, assisting in reducing pain and stress, increasing mobility, improving sleep habits and physical fitness, while helping patients return to activities they may have been unable to do due to their health limitations.

According to the Office of the Assistant Secretary for Health, approximately 1 in 4 adults, 1 in 15 children, and 3 out of 4 seniors have multiple chronic conditions.

A goal of the healthcare system in chronic care management is to support patient self-care. CCM places a greater emphasis on individual behavior and a person’s responsibility in managing their health more effectively and independently. In order to monitor their health and any changes in it, patients with chronic conditions must take action.

Patients should be informed of the advantages of their treatment and urged to stick to it. Studies demonstrate that those who are included in decisions concerning their wellbeing get improved health results. Obviously, for some ailments a cure might not be possible; however, for something like diabetes, an uplift in the person’s condition and lifestyle is attainable. The optimum system for those with multiple chronic conditions is combining dedicated patients and connected medical professionals.

The Major Challenges of Chronic Care Management

Researchers have found, however, that patients who are very ill tend to be less engaged in their care. Lack of engagement makes patients unable to take control of their health. When a person is able to manage their health independently, a focus on self-care and self-management is more appropriate.

Patients and medical care providers both face many difficulties in managing chronic health issues. As individuals suffer from more chronic conditions, their risk of passing away, being hospitalized, or having poor medication interaction rises. Several chronic diseases directly influence a person’s ability to perform day-to-day tasks. People with multiple long-term illnesses typically require more extended and frequent visits to the doctor than acute care needs demand. It is necessary for healthcare professionals to work well together in order to avoid fragmented treatment. In addition, these patients have a greater chance of receiving conflicting advice from their doctors. Treatments for such conditions are often complex, making it hard for patients to adhere to the recommended course of action effectively.

Increasing spending on chronic diseases among Medicare beneficiaries is a major contributing factor to Medicare’s overall spending growth.

Chronic care can be costly in the US, with 66% of healthcare spending attributed to it. In fact, two-thirds of Medicare beneficiaries have multiple chronic conditions. On top of this, they can face large out-of-pocket expenses such as pricey medications. Recently, Medicare started compensating providers for chronic care management services – before this however, reimbursement was hard to come by.

Geographic disparities in chronic disease are a challenge for care management. For instance, prevalence of conditions like diabetes, obesity and heart disease tend to be more common in the southeastern US than the rest of the nation. Yet the cost of treating them does not always correlate. For example, although 16% of Texans suffer from heart disease, Maine residents afflicted with this condition account for only 10%, but they incur almost $24,000 in annual costs per beneficiary — higher than Texas’ average cost. Michigan’s Medicare beneficiaries with diabetes cost approximately $16,000 annually while those in New Mexico pay a much lower figure at $13,000.

There are troubling disparities in health care across racial, ethnic, and gender lines. For example, studies have indicated that non-white patients have a 33% greater chance of death after heart surgery, such as a coronary artery bypass graft. Research has also revealed that women were two times less likely to be tested for Hepatitis C than men; Carribean Islanders also had a much lower predicted probability of screening for the virus than other ethnicities. Colorectal cancer has seen higher mortality rates among non-white patients, in addition to poorer outcomes following treatment. Moreover, the location and receipt of appropriate care can often predict survival from this type of cancer.

The Evolution of Chronic Care Management

Medical researchers began trying to understand and research chronic care and its phases and stages in the 1980s, when chronic care management became a relatively new field of medicine. Several years have passed since then, and significant efforts have been made to develop treatments and research on how chronic illness affects the body and mind.

It is projected that 157 million Americans will have chronic diseases by 2020, with 81 million of them having multiple diseases.

With the growing number of chronically ill patients, there will not be enough primary care health professionals available to meet the demand. As the number of people with chronic conditions increases, a solution to the rising demand for health care may be to increase the role of registered nurses and recruit more people into nursing.

Chronic care management software is becoming increasingly popular as the number of Americans with chronic conditions increases.

What’s in the Chronic Care Management Model?

A chronic care model has been developed by the MacColl Center for Healthcare Innovation to address the shortcomings of chronic care management today. There are a number of deficiencies, including a lack of compliance with established practice guidelines, a lack of coordination between healthcare providers and follow-up with patients, and inadequate patient self-management training.

As part of the chronic care model, the Health System, Delivery System, Decision Support System, Clinical Information System, Self-management Support System, and Community Resources will be reform and strengthened. An informed patient, a prepared care team, and reformed systems will lead to better outcomes.

Chronic Care Management in Medicare

The Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management as a critical component of primary healthcare.

As of 2015, Medicare began paying for chronic care management services, including non-face-to-face coordination services, under the Medicare Physician Fee Schedule.

A Medicare comprehensive care plan typically includes, but is not limited to, the following:

• Current health conditions
• Prognosis of conditions and treatment outcomes
• Measurable treatment goals
• Pain management strategies
• Intervention plans and identification of individuals responsible for each intervention
• Management of medications
• Services for the community and social welfare
• Collaboration with other health care providers

Review and revision of the care plan on a periodic basis, as necessary

There were 58 million Medicare beneficiaries in the United States in 2017. Two out of three Medicare recipients have multiple chronic conditions.

Chronic care management services can only be billed to Medicare by physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants.

A doctor or other practitioner should advise and coach the patient to come up with the optimal treatment plan. The patient should be the main manager of the chronic disease. In order to provide the patient the best chance of controlling their own disease and to lessen the physical, psychological, social, and economic effects of chronic illness, the practitioner and patient should collaborate to devise strategies.

Professionals who may provide and bill CCM services

During a given calendar month, only one physician or other qualified health care professional can provide CCM services to a beneficiary. It is possible to provide services by a clinical staff member, but they must be billed under one of the following categories:

• The physician
• Nurse specialist (CNS)
• An NP is a nurse practitioner
• PA (physician assistant)
• Nurse midwife certified

In the state where the services are provided, non-physicians must be legally authorized and qualified to provide CCM.

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. 

Why Patient Engagement is Critical for Chronic Disease?

Chronic disease management is a complex and ongoing process that requires the active participation of patients. Studies have shown that patients who are actively engaged in their own care have better health outcomes and experience fewer complications.

There are many reasons why patient engagement is so important in chronic disease management. First, patients who are involved in their own care are more likely to adhere to treatment plans and take their medications as prescribed. They are also more likely to make lifestyle changes that can improve their health, such as quitting smoking or eating a healthier diet.

Patients who are engaged in their care also tend to have better communication with their healthcare providers. This open communication can help ensure that patients receive the best possible care and treatment for their condition. Additionally, patients who feel like they are a part of their own care team are more likely to be satisfied with their overall experience.

Engaging patients in their own care is essential to providing high-quality chronic disease management. Patients who take an active role in managing their disease will experience better health outcomes and have a better overall experience with the healthcare system.