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The Politics of Health Care

Medicare's Best Program: Chronic Care Management

Published April 26, 2016 11:51 AM by Monique Barrett

[Editor's note: Nat Findlay, CEO, Hello Health, originally wrote this blog.]

Medicare in 2016
Medicare has existed in many forms since its inception under LBJ over 50 years ago, but it's safe to say the program has certainly grown in complexity and range since its humble beginnings in 1965.

Today, an estimated 44 million patients are currently enrolled in Medicare, with this number estimated to balloon to 79 million by 2020. With the move to value-based care (VBC) in full swing, it's expected that Center for Medicare & Medicaid Services (CMS) will continue to expand its services to better treat the costly and at-risk patient populations who make up a large chunk of eligible Medicare beneficiaries.

In the past few decades, CMS has greatly improved the care of Medicare patients, paying for mammograms, bone density testing, colonoscopies, etc., all of which have had a direct impact on patients' care and outcomes. Further, initiatives encouraging individuals to be vaccinated against flu and pneumonia have made large strides in ensuring an emphasis on preventative treatments and a stronger care continuum overall.

Despite its successes, one particular thorn to CMS has been the continued trend of readmissions and unnecessary ED visits. No patient population is more susceptible than Medicare beneficiaries with multiple chronic conditions such as Alzheimer's, Diabetes, CODP, and Cancer, to name a few.

Consider this: In 2010 alone, among the 14% of Medicare beneficiaries with six or more chronic conditions, over 60% were hospitalized at least once, accounting for 55% of total Medicare spending on hospitalizations. Further, beneficiaries with six or more chronic conditions also had hospital readmission rates that were 30% higher than the national average.1

In 2014, the estimated annual cost of total readmissions for Medicare was $26 billion, with $17 billion considered "avoidable."2

Obviously, these statistics represent a huge hurdle, as all healthcare stakeholders look to cut costs and emphasize a "lean" mindset in the shift to VBC. This came to a head as we entered 2015, when a new message from the CMS became abundantly clear: Something must be done to stave off readmissions and improve the care of our most at-risk patients.

Chronic Care Management
The solution was Chronic Care Management (CCM), a program that went into effect on Jan. 1, 2015. For the past 15 months, the CMS has been using Medicare CPT Code 99490 to reimburse physician practices for providing monthly telehealth calls to patients with multiple chronic conditions.

In essence, CCM tasks PCPs with improving the care continuum via telehealth services, with the ultimate goal of keeping chronic condition patients from re-entering the hospital or ED, and incurring high healthcare costs.

To bill for CCM, a practice must have designated medical professionals call the patient for a non face-to-face encounter, with each call lasting 20 minutes and covering a range of issues specific to the patient's condition and symptoms.

Further, each CCM call must have the following elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • A comprehensive care plan established, implemented, revised, or monitored.

While CCM is a telehealth service (a fairly new term), it is one that many doctors have been providing to their patients since the days of Dr. Welby's black bag. Telephone follow-ups are a natural part of a primary-care office's workflow, and with a few tweaks, the CMS is now reimbursing doctors for running a program they have long offered at their own expense.3

For many Medicare patients, the usual schedule of four in-person visits per year is not adequate to sufficiently manage their complex care routines. Often, the patient's multitude of medications and treatment instructions require numerous clarifications--the CCM call represents a crucial touch point for both the patient and provider.

Prior to CCM, patients with questions and/or concerns about their care would have to travel to the doctor's office or leave a voicemail to receive feedback. When one considers the limited mobility that affects a large portion of elderly patients, it is easy to see how ignoring seemingly benign symptoms could be the more appealing option. However, as those familiar with chronic conditions know, often simple and untreated symptoms can become complex and potentially deadly in a short amount of time.

To remedy this, CCM requires a dedicated medical professional is always available for patient requests, and supplemented by the monthly telehealth calls, ensure that no patient is left out in the proverbial cold. That is not to say CCM patients should not utilize emergency services - rather the program gives physicians a chance to identify potential problems early, using the CCM insights to better inform treatment decisions and ensure the patient is on the proper path towards a healthy outcome.

A Win-Win for Patients and Providers
The advent of CCM represents a tremendous opportunity for both patients and providers as we move further into 2016. As more reimbursements are tied to risk-sharing agreements such as ACOs, the ability to provide a fuller patient picture will be invaluable for healthcare decision-makers looking to ensure the most cost-effective treatment path.

For primary-care physicians with a large number of Medicare patients, the decision to participate in CCM should be an easy one. At last estimate the national average monthly reimbursement for a CCM patient was $42.91. If primary-care physicians can sign up a majority of their Medicare patients­, then there is a large financial opportunity to not only improve care, but also get paid commensurately for these services as well.

According to a study from the Annals of Internal Medicine, a "typical" practice with about 2,000 Medicare patients could generate more than $75,000 net revenue per full-time physician if half of their eligible patients enroll in CCM.1

Beyond potential ROI, the most encouraging example of the CCM's effectiveness has been the overwhelmingly positive response we've received from patients who have been in the program for the past year or so. In my role as CEO of Hello Health, I've had the pleasure of speaking with numerous CCM patients to hear their experience with telehealth and our specific services.

Many of these individuals have serious medical issues, often lacking mobility, full eyesight and suffering from a number of painful symptoms that need constant medication and monitoring. In many cases, telehealth is the only viable way for them to receive care that makes an actionable difference in their day-to-day health.

Despite this promising feedback, Managed Care Magazine reports last year CMS officials said they paid for about 275,000 Medicare beneficiaries who received CCM on average of three times; paying out a total amount of $12 million to participating doctors. When one considers that there are currently 35 million Medicare patients eligible for CCM, this means that only a small portion of patients have been able to benefit since Jan 1, 2015.

In other words, CCM is making strides, but is nowhere close to reaching its full potential in terms of patient enrollment and additional revenue generated for PCPs. With these statistics and the continued push for value-based care, the message to primary-care physicians and their patients is clear: These are the five most important numbers for a Medicare patient and their physician- 99490.

Nathanial Findlay has held executive positions in the healthcare industry for more than 20 years. A veteran of successful start-ups as well as the Fortune 21 company Cardinal Health, Nat's experience honed an entrepreneurial perspective and enthusiasm that inspired him to start Hello Health in 2008. With a background also including accounting and law, Nat continues to work at the forefront of the evolution of modern primary healthcare. Nat's mission is to use the Internet and mobile technology to redefine how patients interact with their physicians and manage their own health.

References:

1. HHS.gov. "A Pathway To Improving Care For Medicare Patients with Chronic Conditions." Available at: http://www.hhs.gov/asl/testify/2015/05/t20150514a.html#_ftnref14

2. Center for Health Information and Analysis. "Performance of the Massachusetts Health Care System Series: A Focus on Provider Quality." Available at: http://www.chiamass.gov/assets/Uploads/A-Focus-on-Provider-Quality-Jan-2015.pdf

3. CMS.gov. "Chronic Care Management Services." Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

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