Laying the Groundwork for Implementing a Chronic Care Management Program

First the number

1. 45% of the world’s population is affected by chronic disease
2. 60% of worldwide deaths are caused by chronic disease
3. 4% of the global annual GDP represents the economic burden associated with chronic disease
4. 17% of the US GDP is spent on healthcare, and chronic disease makes up 75% of this expense
5. 80% of chronic disease can be prevented

The numbers are staggering, so what do we do about this? Well, as individuals we can exercise more, eat better and lose weight, but that is not what I am asking. I mean what do we do as a society? Fortunately, the healthcare industry as a whole is working on the problem. However, in this, and successive blogs, I will focus on the path that CMS is taking to address the issue of Chronic Disease Management.

What is CMS Doing About it?

As we all know now, CMS launched the now CPT code (99490) which pays providers an average of $42 for 20 minutes of non-face-to-face contact with Medicare Beneficiaries diagnosed with 2 or more chronic conditions. We are now over 10 months into the program. So how is it going? Or to (mis)quote Field of Dreams, “If you build it will they come?”

According to a recent survey by PYA, as of October 2015 only about a quarter of eligible providers had launched CCM programs and only about half of those had actually billed for those services. According to CMS, approximately 100,000 patients (out of a possible 25 million) had been billed for so far. Given that providers are finally being reimbursed for work that they are already doing, why is adoption so low?

There are a number of reasons for this low response. They generally fall in the following three categories:

1. Providers aren’t comfortable that they understand the rules and don’t have the time to do the necessary research
2. Providers don’t have the resources needed to perform the service
3. Providers do not believe that they can make money performing this service

These are of course valid concerns and even more so for small practices.

I won’t spend much time explaining what the rules and regulations are but you can find a very good summary on the CMS website. What I do want to point out is that the free market and good old entrepreneurship has come to the rescue. There are now many companies that will provide a combination of software and services to help the provider deliver this service. However, not all such companies are created equal. Many are fly by night operations that are trying to do a dot com like land grab by launching a purely manual, bare bones service and signing up as many providers as fast as they can and then worrying about the quality of the service at a later time. Many are basically call centers that do not have the CMS required technology and are just peddling bodies on the phone, and still others that just provide software for use with the service. Depending on your specific circumstances, any of these may be the right partner for you. Additionally every EHR supposedly has a Care Management module in their system. So…

7 Questions to Ask a CCM Vendor

If you are among the 74% of providers who haven’t taken action on deploying a CCM program, what should you do? If you are hesitating because of any of the three reasons above, then the solution might just be to select a care management service provider that offers a turnkey service. In any case, you will need a Care Management (CM) software system. However, as in everything else in life, all are not created equal.

Below are 7 questions you should a potential vendor during your care management software selection process:

1. Do they have a software system for care managers to use that can track and maintain a longitudinal health record for each patient (a Medicare requirement)?
2. Does their CM system accept patient summaries in the form of a CCD or CCDA (a Medicare requirement)?
3. Does their CM system track care provider time and maintain a log of all activities in case there is a CMS audit (remember you are the one billing CMS and will be held responsible for any inaccuracies or shortcomings)?
4. Does their CM system provide decision support tools that help the care managers track where the gaps in the care of the patient are, what assessments need to be performed, and what goals need to be set for each patient. This is critical to ensure that what CMS is trying to do (I.e. Improve the care of the sicker patients) actually gets done?
5. Are they able to connect to your EHR system and identify the patients that qualify for the CCM program?
6. Do they provide 24×7 coverage?
7. Are their Care Managers trained in providing evidence-based, patient-specific care management?