The Chronic Care Management CPT code (99490) allows providers to collect approximately $42 per qualified patient per month for providing 20 minutes of non-face-to-face care management services to Medicare beneficiaries that have at least 2 chronic conditions. This, as with most new CMS initiatives, has as its ultimate goal the objective of improving patient outcomes and satisfaction. How do we get from this fee- for-service reimbursement to improved outcomes?

The Grand Plan

CMS has an overall plan that moves the healthcare system into value-based payments at a breakneck speed. In order to get there, CMS has defined 4 categories of payments which are as follows:

• Category 1—fee-for-service with no link of payment to quality
• Category 2—fee-for-service with a link of payment to quality
• Category 3—alternative payment models built on fee-for-service architecture
• Category 4—population-based payment

As shown in the figure below, CMS plans to have 90% of all payments at a minimum linked to quality of care (as measured by CQM scores) by 2018 and by then at least 50% of payments will be under alternative payment models which typically will link them to patient outcomes. That is about $500 billion!

Care Management
Percentage of Medicare FFS payments 2016 & 2019

What does this change mean for the new fee-for-service CCM code? Basically, it means that this code will not stay the same for very long. We expect that soon various Clinical Quality Measures (CQMs) will start to be applied to the patients receiving this service and within a year or two after that this population will need to start demonstrating improved clinical indicators. Of course politics could shift this change, but the overall trend will remain the same.

What Does this Mean for Physicians and Hospitals Now?

Knowing where the train is headed, we must get aboard with the right equipment, otherwise we won’t make it to our destination. CMS has created a nice FFS ramp to ease providers into this new world. However, the decisions providers make on the tools to use for the FFS part will have a great deal of impact on their success as these codes transition towards outcomes. The vendor/partner that the provider picks now will impact numerous factors down the line, including:

• Impact on quality scores
• Impact on care standardization (acute and post-acute)
• Impact on driving additional visits, labs etc.

Keep in mind that one of the largest factors impacting the quality of care is the variation in the standard of care. This is especially true for the post-acute environment where the quality of care is greatly influenced by the training and dedication of the clinical and support personnel involved. Significantly, and as the manufacturing world learned in the ‘80s and ‘90s, until you reduce the variability in the processes being applied, you cannot improve overall performance. To put it another way, if your shots are all over the target, trying to improve accuracy is difficult. Once you have bunched your shots so they all fall in one area then getting them to hit the center of the target is a relatively simple matter. Similarly, once we have reduced the variability of care by controlling and influencing care delivery by providing – based knowledge at the point of care, we can start making significant strides towards improved clinical indicators and outcomes. But, how can we do that?

What Tools Should be Selected?

When providers sit down to select a CCM partner they need to think about how their partner’s Care Management (CM) platform will impact the factors mentioned above. There is one set of capabilities that rise above all others in importance when one wants to achieve the goals mentioned above. This is the depth and breadth of the clinical knowledge (or decision support) embedded within the CM system workflows. Crucially, the CM system needs to be able to achieve this in real-time and do so within the clinical workflows. Unless the CM system has the ability to access a very large body of evidence-based knowledge, and can inject that into the workflow as a set of Alerts, Goals and Assessments in real-time, one will not achieve one’s goal of reduced variability and improved care.

So, as you move into providing CCM services and select a partner to help you in this journey, make sure that they also value improving the quality of care as much as you do.