Outsource or In-house: Two Key Questions to Ask When Building Your Chronic Care Management Program

Care for chronically-ill patients represents the most expensive segment of Medicare, with more than 93% of spending (PDF, 4.9 MB) directed for beneficiaries with multiple chronic conditions. And with more than 171 million Americans estimated to have one or more chronic condition(s) by 2030, according to a Rand Corporation report, the cost of chronic care management will continue to impact the nation’s healthcare spending.

The need for effective chronic care management is growing, but how can overbooked physicians handle these patient encounters (and reimbursement issues) with finite resources? Physicians must consider outsourcing chronic care management if providing such care by the practice is not feasible.

Jeb Dunkelberger, executive director, Accountable Care Services & Corporate Partnerships at McKesson, acknowledges the resourcing challenges created by the various quality programs.

“It’s no secret that bandwidth is an enormous challenge for everyone,” Dunkelberger said. “Between fulfilling the requirements of CMS programs like meaningful use and the Physician Quality Reporting System and meeting the day-to-day obligations of clinical documentation, coding and revenue cycle management; most physician groups are already at capacity when it comes to juggling regulatory and administrative responsibilities.”

Given these challenges, outsourcing your chronic care management program can simplify the overall care management and reimbursement processes. The decision about whether to have an in-house program or to outsource chronic care management services can be framed in two questions:

  • Can the practice consistently and appropriately meet all compliance requirements?
  • Which path would provide the best patient outcomes at the most efficient cost?
Can the practice consistently and appropriately meet all compliance requirements?

Among the requirements outlined by the Centers for Medicare & Medicaid Services (CMS) for chronic care management is a 20-minute minimum care management console with each patient per month. Such communication can either be face-to-face or remote via telephone, the Internet or another telemedicine device.

Given this mandatory 20-minute consultation for each patient, the time requirements can quickly add up in large patient groups or facilities.

With a Medicare patient population of 300 per practice (national average), with 66% of those having two or more chronic illnesses and a 25% enrollment rate, if each physician were to spend no more than 20 minutes per patient, than a practice would require more than 16 hours of additional staff time per month just on the consultations.

In addition, a practice must consider the additional time required to meet the program’s documentation and billing requirements. And, since compliance is essential for reimbursement, meeting all program elements may require further investments in technology and additional staff.

A trusted chronic care management service provider would be able to facilitate these mandatory meetings and provide services ranging from patient care plans to claims queries to managing documentation and billing requirements. In any case, outsourcing puts far fewer requirements on the practice’s current medical and administrative staff.

Although outsourcing doesn’t absolve providers of all obligations, it gives them more time to serve patient needs and focus on improving care outcomes.

“Essentially, the practitioner is the quarterback and they must act if the situation demands it,” Dunkelberger said. “They can’t just see this as another administrative headache, or the outsource provider as just another vendor.”

Which path would provide the best patient outcomes at the most efficient cost?

Before deciding whether to in-house or outsource a chronic care management program, providers must determine if costs associated with new staff and training would outweigh vendor costs against potential revenue, and which method would improve patient outcomes.

Hiring new staff to call patients with chronic conditions is an option, assuming that proposed revenue will offset any additional payroll expenses. However, extensive training would be required on the intermediate and ongoing steps to satisfy the requirements outlined by CMS.

Internal structures could also be influenced by changes in a chronic care management program itself. If CMS decided to fundamentally overhaul or sunset the program, provider organizations with new resources would likely face negative consequences.

A vendor could help providers guard against these factors by offering a full spectrum of services, including but not limited to:

  • Providing patient directed literature explaining the program’s requirements and benefits
  • Providing oversight of beneficiary self-management of medications
  • Facilitating referrals to other providers
  • Coordinating with home and community-based service providers
  • Ensuring timely receipt of all recommended care services

Compliance with the chronic care management program requirements is essential for reimbursement, and meeting them on your own requires significant investment in new technology and staffing — or instead, working with a trusted vendor to provide such services.

Chronic Care Management eGuide

Jeb Dunkelberger

About the author

Jeb Dunkelberger is the Vice President of Accountable Care Services and Corporate Partnerships for McKesson's Business Performance Services division. In this role, Jeb integrates a plethora of health care stakeholders in revolutionary care delivery models designed for the evolving complexities of today's health care sector. Formerly, Jeb served as Executive Director of Physician Engagement for Accountable Care Services, where he was responsible for physician recruitment, alignment, and engagement, as well as managerial oversight within multiple health care delivery models. Jeb holds health degrees from Cornell, London School of Economics, and Virginia Tech and brings close to a decade of experience in the healthcare sector.