It seems like every day I read another article about the CMS Chronic Care Management (CCM) Program and how not as many organizations are participating as anticipated. It is important to note that Medicare is not the only carrier to offer this program, as commercial payers have similar reimbursement programs that would qualify for organizations. Overall, neither the CMS Chronic Care Management nor private payer programs have seen enough traction to change the way healthcare delivery is administered. To date, CMS has acknowledged only about 100,000 claims out of a pool of upwards of 35 million eligible beneficiaries (0.29%).

Not to insert a long explanation of the program, but to re-familiarize you, this program creates payer coverage for spending 20 minutes per month directly monitoring patients with chronic conditions. The monitoring can be done in the form of a phone call by a member of clinical staff to check on the patient’s general health, medication use, key measures (e.g. diabetic glucose levels), or to stay in touch with the patient. It saves an office visit, keeps patients well-monitored, and can get a CMS (Medicare) payment of about $42 per patient per month. Win-win-win!

Like so many other programs, adoption can take time, and each program can have its own challenges. What is surprising about this program is that it offers a substantial financial benefit to healthcare organizations with less work on the part of the providers. Outside of the financial opportunity, the program also addresses another key issue providers feel strongly about, specifically, increased interaction with patients with chronic diseases. In fact, a recent poll of 45,000 primary care providers and those who were participating in a CCM program found “84% of physicians believe it is having a positive impact on patient care.” So here we have a program, supported by payers, that saves providers time and addresses a key area of concern by providers that is not always properly addressed. Therefore it begs the question, if it is valuable to patients in managing their chronic conditions, and the revenue stream is present, why doesn’t everyone hop onboard the CCM bandwagon? Through my interaction with providers, there appear to be three key objections to implementing a program like this: 1) Internal organizational issues  2) EHR readiness  3) Provider skepticism.

• Who owns the program? It is really not an IT initiative. Depending on the size of the organization, small to medium size organizations may feel their IT department is responsible for the rollout. In most organizations, the decision to implement this program falls in line with the transitional care that is taking place with new healthcare reform models, and this is just the start of things to come. Organizations will need to define quality programs if not already in place and will need transitional care teams to navigate these waters. This program may be the first that has organizations looking at new departments to manage the future in healthcare IT.
• Lack of Care Plans in Electronic Health Records. Most certified Electronic Health Records, which are required for certain aspects of CCM (problem lists, medications), don’t have care plan modules already in place. Organizations need to either develop them or utilize a third party application.  A third-party application disconnects the care plan data from the patient’s EHR chart unless integration is present. With more and more transformational programs, such as PCMH and ACOs, care plans will be vital to have in EHRs.
• How to track the non-face-to-face time. Again, similar to not having care plans in the existing EHR, having the ability to easily identify enrolled patients and track the time isn’t functionality available in many EHRs. Some clients use long excel lists to manage dates/times/lengths of calls to know when the time has been met and when to bill for the 99490 code.
• Staff Utilization. Do existing staff have the bandwidth to meet this demand, or would this require additional hires? Waiting on new job requisitions to be approved and hired resources to be onboarded can delay a program moving forward, however, the upside is that revenue from the program can be used to cover the additional required resources.
• Provider Buy In. Providers will be required to obtain patient consent and complete a care plan for every CCM patient. This will take time to walk through each patient that qualifies, and all too often, we hear “there isn’t enough time to provide adequate patient care, so how can we ask for more time to get consent and complete a care plan?”
• Patient Engagement. If patients don’t see the value in participating, they likely won’t sign the consent or agree to a co-pay of up to 20% of the required coinsurance. Patients will need to understand the importance of having someone check up on medications regularly, and managing them closely will likely decrease hospitalizations and improve symptoms, which can be much more costly and impact their day-to-day lifestyles in the long run. Also, for patients with supplemental insurance, this may cover the co-pay. In addition, organizations can potentially consider financial hardships.

For organizations that could use some guidance or help with these issues, Galen Healthcare Solutions has developed a comprehensive Chronic Care Management program to assist our clients. Key areas include: CCM Program Development with documented workflows/processes and identification of gaps for success, care plan development in the Electronic Health Record, Reporting Tools to track the time spent with patients, and assistance in rapid enrollment of patients/program oversight to improve adoption and revenue return on investment. Join us for a free webcast on December 9 to hear how your organization can begin their CCM program or contact us below for more information: