Quality of care through optimized performance is today’s mantra in healthcare. It underpins our industry’s pursuit of the Triple Aim: to improve the experience of care, improve the health of populations and reduce per capita costs of healthcare.1 Achieving these three interdependent goals relies heavily on managing chronic conditions for our nation’s Medicare patient population.

The chronic condition burden

The Centers for Medicare and Medicaid Services (CMS) says about 93% of total Medicare spending is on beneficiaries with multiple chronic conditions.2 As the population ages, hospitals and physician practices face the daunting challenge of improving quality of care for more and more chronically ill patients while also containing costs.

Spending and cost containment aside, chronic conditions such as heart disease, stroke, cancer, type 2 diabetes, obesity and arthritis are a tremendous burden on society and on us as people. Chronic conditions lead to seven of 10 deaths in the U.S. each year. Arthritis is the most common cause of disability. And diabetes is the leading cause of kidney failure, new cases of adult blindness and lower limb amputations outside of injury. Ironically, many of these conditions are also the most preventable and responsive to intervention of all health problems.3 Proper chronic care management can help prevent complications, reduce unnecessary costs and improve overall health.

Chronic conditions’ link to quality of care

Improving quality of care is a high priority for CMS, as evidenced by recent actions. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law in April 2015, changes the way Medicare rewards clinicians for value-based care over volume. It also streamlines multiple quality programs under the new Merit-based Incentive Payments System (MIPS), set to take effect Jan. 1, 2017. About 90% of physicians are expected to follow the MIPS path versus riskier alternative payment models, and be scored against other clinicians on three performance categories: quality, improvement activities, and Advancing Care through Meaningful Use of Certified EHR Technology.4 Quality measures, which are defined as appropriate use, patient safety, efficiency, patient experience and care coordination, will account for 60% of a provider’s MIPS Composite Performance Score.5

Given its weight in value-based reimbursement, quality should be clinicians’ primary and most immediate focus. Offering chronic care management services is the key to improving quality of care, since two-thirds of Medicare beneficiaries have two or more chronic conditions.6 An effective way to address these high-risk patients is with CMS’ Chronic Care Management (CCM) program, introduced in January 2015.

Why Chronic Care Management?

CCM reimburses physicians under CPT® code 99490 for providing non-face-to-face care coordination services to eligible Medicare patients with two or more chronic conditions. The CCM program allows providers to proactively manage chronically ill patients’ health outside the normal office setting and be reimbursed for those services, which have typically been provided without compensation. Here’s how CCM works:

  • Providers must deliver at least 20 minutes of non-face-to-face, chronic care services per month.
  • The average reimbursement is $40.00 per enrolled patient per month.
  • CCM components must include a comprehensive care plan, medication reconciliation, transition of care, care coordination between providers and 24/7 access to urgent care for patients.

CCM clearly puts patients’ needs first, which leads to higher patient satisfaction and engagement. Research shows, for example, a positive correlation between care coordination (a CCM requirement) and patients’ perceptions of care quality.7 Other benefits of participating in CCM include:

  • Fewer hospital admissions and readmissions. A recent study shows patients who thoroughly understand their after-hospital care instructions are 30% less likely to be readmitted or go to the emergency department.8
  • Improved patient self-management. Reinforcing compliant behaviors and medication management help patients stay on track.
  • Cost control. Research shows that, on average, costs for patients with uncoordinated care were 75% higher than matched patients whose care was coordinated.9
  • Progress toward meeting MIPS requirements. CCM participation hits 33 measures in the MIPS Quality category including 22 high priority measures. It also fulfills some CPI activities, addresses cost/resource use by decreasing avoidable interventions and encourages use of EHRs.
Time for a strategic step forward

Despite the benefits, a recent McKesson poll of CCM webinar attendees indicated nearly 60% of providers are not currently billing for CCM under CPT code 99490.10 This coincides with a CMS report that only 275,000 of an estimated 35 million Medicare beneficiaries who would qualify for the CCM program received services in 2015.11 Reasons for the slow uptake include a simple lack of awareness of the program, complexity of Medicare billing rules, compliance concerns, patient enrollment and 20% co-pay, and health systems’ or physician practices’ lack of organizational support, infrastructure and technology.

CMS is trying to make CCM adoption easier. A few months ago, they relaxed a few technology requirements and are now proposing to simplify some payment policies in 2017. Every little bit helps. The Medicare population will only continue to grow and providers must be prepared to improve these patients’ quality of care, satisfaction and retention. CCM is a relatively easy, strategic first step for providers who want to transform their practices, improve quality of care and thrive in the value-based reimbursement era. In addition, commercial payers have begun following suit and offering reimbursement for CCM. In the future, programs like CCM will become the norm, and providers need to be prepared to start offering these value-based care services.

Learn how McKesson Chronic Care Management Services can help your practice improve quality care and increase value-based reimbursement.

Outlook for Chronic Care Management and Physician Payments in 2017

1“The Triple Aim: Care, Health, And Cost.” Donald M. Berwick, Thomas W. Nolan and John Whittington, accessed Oct. 5, 2016.
2Medicare Dashboard Advances ACA Goals for Chronic Conditions. March 28, 2013.
3Chronic Diseases: The Leading Causes of Death and Disability in the United States. last updated Feb. 23, 2016.
4“Few docs ready for risk under MACRA.” Shannon Muchmore, Aug.13, 2016.
5MACRA Notice of Proposed Rule Making (NPRM) Summary of Identified Key Provisions in the Proposed Rule.
6Multiple Chronic Conditions, Centers for Medicare and Medicaid Services. last updated Jan. 20, 2016.
7 Danmedj Issue 2016 03/A5200
8“A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial.” Annals of Internal Medicine, Feb. 3, 2009.
9The Value of Nursing Care Coordination. American Nurses Association, June 2012.
10 Internal McKesson Business Performance Services webinar poll.
11 “Medicare’s CCM Telehealth Program Gets a Bit of Good News,” Eric Wicklund, July 25, 2016. 

Bill Sillar

About the author

Bill Sillar is National Channel Manager for McKesson Business Performance Services, supporting McKesson’s value-based care services. Sillar has been with McKesson for 10+ years and has played a pivotal role in helping healthcare organizations bridge the gap as they transition from a fee-for-service to a value-based reimbursement payment model.