The Centers for Medicare & Medicaid Services (CMS) officially released its final 2022 Physician Fee Schedule, including increased reimbursements for chronic care management (CCM). CMS began recognizing chronic care management in 2015 when it first included CCM reimbursements in its physician fee schedule. Since then, CMS has considered CCM a “critical component” of primary care, helping patients managing chronic conditions achieve overall better health.
The goal is simple: improve patient outcomes while reducing the cost of treatment. Six years in, the subtext of the scheduled reimbursements increase for 2022 is that CCM has proven to be an essential part of the care continuum, particularly in the wake of the Covid-19 pandemic, and has real value for patients, providers, and payers.
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Tom Ferry Tom joined Engooden as President and CEO after two years as a member of the board. Prior to Engooden, for nearly 20 years Tom was CEO of Curaspan, a discharge planning technology company that he co-founded in 1999 and sold in 2016. Before Curaspan, Tom held multiple business development roles at American Hearing […]
Although telehealth usage has stabilized since its immediate surge in March 2020, data from McKinsey reveals usage grew 38X higher than before the pandemic. The same report reveals while telehealth remains nascent, it improves healthcare efficiency, reducing the cost of care among chronic populations up to 3%. The potential value will be higher as providers improve at designing and executing CCM plans.
How CCM works
CMS designed chronic care management to compensate practitioners providing care to patients beyond the standard office visit, incentivizing them to be more proactive in caring for patients suffering from complex chronic diseases. This program resulted in more care as providers began engaging more with these patients, taking a more active role in their care, and improving outcomes while reducing treatment costs.
Medicare reimbursement to providers is based on at least 20 minutes of clinical staff time dedicated to each patient per month. Although it is similar to its sister program, principal care management (PCM), chronic care management requires the patient to have two chronic conditions to qualify instead of one. The conditions eligible under this initiative included, but are not limited to:
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A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
- Cancer
- Cardiovascular disease
- Chronic Obstructive Pulmonary Disease
- Depression
- Diabetes
- Hypertension
In addition, each patient must have a comprehensive care plan signed by their providers. Providers and their care teams are then eligible for reimbursement as they work with patients to execute the plan, including:
- Coordinating care between hospitals, pharmacies, and clinics
- Managing prescriptions
- Providing education regarding a patient’s conditions and medications
- Providing round-the-clock access to emergency care
- Establishing and meeting treatment goals
- Managing community services such as transportation to appointments
- 20 minutes or more of monthly dedicated CCM services
Benefitting rising-risk patients
CCM is particularly beneficial to patients in the rising-risk population. These patients may have multiple chronic conditions but are unaware, unwilling, or unable to access the necessary care to avoid becoming high-risk. Utilizing CCM services to meet the needs of high-risk patients is vital to preventing severe health events. However, the value to rising-risk patients — a large portion of the United States population — is tremendous, potentially preventing a catastrophic health event that could result in advancing into a higher-risk category.
The American Hospital Association reports only 20% of overall health is determined by clinical care. At the same time, additional research reveals that the care between clinical appointments is the most essential for achieving better overall health outcomes. The chronic care management touchpoints and services occurring between provider visits create a more holistic view of a patient’s health, including socioeconomic factors and health behaviors that often go undetected and significantly influence their overall wellbeing. Without any insight into these factors, developing better, more consistent person-centered primary care is much more difficult.
The future of CCM
By increasing reimbursements for CCM, CMS is signaling the value these services provide and should motivate providers to offer a connective care model between office visits. Comprehensive care plans drive better patient outcomes, reduce healthcare costs, and increase the quality of life for the many Americans living with chronic conditions.
As recently as 2018, research from the Center for Disease Control reported that over 50% of adults in the study suffer from at least one of 10 selected diagnosed chronic conditions. For many patients, chronic illnesses such as diabetes and lung disease often stem from lifestyle choices and habits. When patients embrace healthier behaviors, they have a better chance to manage and improve their condition. CCM ensures these patients are getting regular touchpoints outside of periodic office visits. Whether it’s a reminder about a recent prescription or simply having a human connection (something crucial to elder care), CCM helps patients follow through on treatment. The CMS reimbursement increase creates a stronger incentive for providers to put in place programs that help manage patient care between doctors’ visits, reduce risk levels, and improve patient and provider outcomes.
Photo: AndreyPopov, Getty Images
Tom joined Engooden as President and CEO after two years as a member of the board. Prior to Engooden, for nearly 20 years Tom was CEO of Curaspan, a discharge planning technology company that he co-founded in 1999 and sold in 2016. Before Curaspan, Tom held multiple business development roles at American Hearing Centers, Thermo Electron Corporation, and Specialty Chemicals Business, a division of Monsanto.
