By now we've all heard about the Chronic Care Management (CCM) Program from the Centers for Medicare and Medicaid Services (CMS), which began January 1, 2015. Under the program, CMS will pay providers for managing Medicare FFS patients with 2 or more chronic conditions.
But the question many health systems with employed physicians are asking is, how much revenue could an average physician group generate under the program? And what investments would be needed to participate in the program?
To answer those questions, let's take a look first at reimbursement assumptions for one physician:
• Patient population for one physician = 2,500 patients
• 30% of this total population is Medicare = 750 patients
• 70% of Medicare are FFS = 525 patients
• 70% of this FFS group have 2 or more conditions = 368 patients
• 75% of patients consent to participate = 276 patients
• Each patient can be billed 1x each month = $42
• Monthly recurring revenue per physician for 276 patients = $11,596
• Annual revenue per physician = $139,104
For a group of 100 physicians, this amounts to annual revenue totaling nearly $14 million.
In general, patients with multiple chronic conditions are the most likely candidates to be managed by a care manager in a patient-centered medical home (PCMH) and have the greatest opportunity and need for care coordination activities. The typical patient in this category sees several specialists, takes 14 or more medications, and has care opportunities and lifestyle risks for each condition. They also account for the highest number of 31-day readmissions and duplicated lab and radiology tests out of any patient group.
As a result, not only is the CCM initiative a significant reimbursement opportunity; it also will help you decrease total costs and improve quality of care.
Program Investments
Providers will, of course, have to consider the investments involved in coordinating additional care services. However, the money earned in the program can offset the cost of hiring certified staff and employing automation to cover the extra time spent on care management and coordination.
For example, investments might include:
• Additional hours of staff time spent with CCM patients; CMS requires that a care team member spend 20 minutes of non-face-to-face time per patient per month on chronic care activity.
o For example, 20 minutes x 276 patients = 92 hours/month
o In addition, you should assume some prep and documentation time before and after the interaction.
• Additional hires (such as a CME, LPN, or Case Manager) ranging from $40K to $100K per year.
o It may be a mix of these professionals to manage different levels of acuity.
o For example, 0.5 CM and 0.5 CME = $70K for annual staff expenses.
• Software to document the care plan and time spent
o Phytel has created a whitepaper that might clarify your expense and potential return on investment in this area, "How to Use HIT in Medicare's Chronic Care Management Program."
• 24/7 coverage
o If you are already a PCMH, you would have the infrastructure in place; if not, you will have to factor that into your costs.
Automation Can Help
Healthcare IT can help with a CCM program in several ways, including using a patient-centric chronic disease registry and automated patient outreach to identify and reach your highest risk patients. Automating the process helps you focus your resources on patient care plans, rather than paperwork, and can also limit the amount of FTEs needed to manage the work overall. A physician group would ideally want technology that could help you to specifically identify your most urgent chronic cases. Its tools would:
• Show you which patients require immediate attention
• Deliver precise history and health data on those patients
• Offer easy, effective ways to document your activities and results
• Make it easy to personalize and track patient goals, tasks, interactions, and barriers.
• Let care managers view all the relevant goals and associated tasks for each individual—easily, completely, and at any time.
• Simplify the process of reaching out to patients via automated communications like phone, email and text messaging, to encourage them to schedule a visit or recommended procedures.
CCM Program Requirements
The financial incentive in the CCM program is substantial, but it requires an investment in infrastructure and a commitment to change that many practices may find intimidating. To help you prepare, here is a cheat sheet of the main program requirements.
CCM Program Requirements: An Overview
• Medicare FFS patients with 2 or more chronic conditions are eligible. Patients must consent to participate.
• Providers will receive a monthly payment of $42 per patient per month (there is regional variation). Patients need to pay 20% of this fee.
• Care can be billed for care team activities totaling at least 20 minutes of non-face-to-face "chronic care management services" each month, such as:
o Health coaching over the phone or secure email
o Care coordination and referrals
o Medication management
• Services can be provided by clinical and non-clinical staff, including nurses, health coaches, and certified medical assistants.
• The new payment code is "99490."
• Providers can use and bill for the IPPE (G0402) or annual wellness exam (G0438, G0439) in addition to CCM.
• Providers must use an MU-certified EMR (2011 or 2014).
• Providers must offer remotely accessible care (EMR or other technology).
• 24x7 access to the clinician is required (phone or internet).
• Providers must create individual Care Plans (patient and caregiver).
Overall, the potential benefits of CCM go far beyond the direct payments from Medicare. Engaging in this program also will prepare practices to participate in alternative payment models and value-based reimbursement.
Richard Hodach, MD, MPH, PhD, is chief medical officer of Phytel and author of "Provider-Led Population Health Management."
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