Making the most of chronic care management programs

Regulations issued by the Centers for Medicare and Medicaid Services usually include one part carrot, one part stick.

But when it comes to the 2015 rule creating a CPT code for chronic care management (CCM), it’s all carrots. By implementing a CCM program, practitioners can collect $42 per qualifying Medicare patient, per month, for 20 minutes of non-face-to-facecare. These phone calls and other non-face-to-face interactions were previously not billable, so this is potentially a new stream of income that can also help to modernize and streamline provider-patient communications.

But to achieve long-term success with CCM programs, practitioners need to be thoughtful about whether it’s best to invest in internal staff and technology or to rely on an outside partner to manage this new function. When considering which approach will work best for a particular practice, it’s important to consider two important questions:

1. How will you attract and enroll sufficient numbers of patients into the program??
2. How will you create a sustainable program that continues to provide value to patients over the coming months and years?

While there is no one way to create a successful CCM program, there are some recommendations that can help physician practices navigate this process.

Start strong, stay strong
Without a critical mass of patients in the program, it’s hard to make much of a clinical or financial impact. To optimize enrollment, a high level of commitment is required from practitioners to drive strong engagement from clinic staff. Office staff should be viewed as a tremendous asset to drive patient education and enrollment. Provider time is limited, so if the burden is all on them, it just won’t happen. Likewise, if providers aren’t committed, their staff won’t be either. With strong staff engagement, patients can be educated and enrolled in multiple ways prior to being face to face with their provider, leaving the provider with little or no work to complete the enrollment.

Think long term
Once you get patients enrolled in CCM, it’s important to keep them in the program. Patients who don’t understand the value of CCM and why it’s important for them to participate will often drop out of the program within the first three months. Additionally, patients that don’t feel like they are experiencing value from the program will also drop out. Once patients leave the program, the probability of them re-engaging is slim. In order to build a sustainable program, it’s therefore very important to ensure enough staff capacity to consistently provide the service and that the program is structured in a way that makes it meaningful for patients.

Invest time and/or invest money?
The biggest decision healthcare providers will make as they embark on establishing a CCM program is whether to build and maintain the capacity internally or contract with a CCM vendor to administer the program. The right path will depend on a variety of factors including staff size, staff skill level, supporting technologies, patient satisfaction and physician preference.

While healthcare organizations may see insourcing as a less costly alternative, it is important to evaluate the true cost of consistently providing a high value service. That includes recruiting the right people with the right experience, training them, providing the equipment and tools needed to efficiently and effectively deliver the service, management and clinical oversite, and accurate and complete documentation. The most effective way to profitably administer large CCM programs and achieve economies of scale is by building a specially-trained care management call center.

When it comes to smaller clinics, staff may already be at or near capacity, which makes it difficult to provide the service consistently. Staff who are used to face-to-face clinical interactions and workflow would also likely have to be trained about the specific questions to ask and discussion points to have a meaningful dialog with patients and elicit important information over the phone during monthly CCM calls.

Clinics can be highly successful with CCM whether they insource or outsource, as long as they start by prioritizing onboarding and sustainability.

When insourcing makes sense
Insourcing approaches to CCM work best when there is top-down support from executives and practitioners, everyone embraces the goals of CCM, and there is dedicated staff to provide the service. One clinic in Florida launched its CCM program in early 2015 with all these elements in place, providing a very good example of an insourcing approach that works. With buy-in and commitment from all relevant stakeholders, patient enrollment grew quickly to several hundred patients.

In addition to devoting sufficient staff resources, the clinic significantly updated its workflows to develop discipline and consistency around documenting time for activities that previously were not billable, including vaccine reviews, medication reconciliation, addressing patient concerns, sharing records with consulting practices, and care plan updates.

The clinic also prioritized efficiency, aiming to complete the monthly 20 minutes of time in a single call. In addition, they instituted a month end process to complete the calls.

Thanks to the clinic’s high level of commitment and structured approach, it consistently bills three quarters of its enrolled patients each month, and has maintained strong patient retention for well over two years.

In contrast, a large group practice that chose to insource CCM immediately enrolled several hundred patients thanks to strong provider commitment and staff engagement. Unfortunately, the program was not sustainable because the staff didn’t have the time to execute the monthly calls. Their robust enrollment effort ended in a lot of attrition when patients didn’t receive consistent, high value service. Additionally, uneven and inconsistent documentation within the group’s EMR system created unnecessary audit risk around the CCM program. Unfortunately, the majority of patients who quit initially have not rejoined the program.

When outsourcing is best
Outsourcing is a good option for clinics with little excess capacity, limited experience providing telephone care management services, and a desire to enroll and retain more than 25 patients in the program. When selecting your CCM partner, remember the sustainability of the program will depend in large part on the quality of the staff and whether they are using evidence-based methods in their dialogue with patients. These considerations, and not price alone, should drive the CCM vendor selection process. In addition, the right partner should provide resources, tools, and assistance to take as much of the burden of enrollment off the practice as possible. However, be wary of one that says they will do all the work for you. It’s not desirable for your staff to be disconnected from such a critical program.

One clinic in California that decided to do CCM last year recognized they would not have sufficient resources in-house and decided to contract with an outside vendor. Their enrollment process was well thought out and effective, but the clinic realized several months into the program that their vendor—which they had chosen based on price—did not provide enough value to patients to keep them engaged. As a result, patient attrition within the CCM program was close to 50 percent.

Meanwhile, a clinic in North Carolina that decided to outsource their program ultimately eschewed the low-cost bid in favor of a high-quality service delivery partner. The clinic was highly successful at enrolling patients by achieving widespread buy-in from clinicians with strong staff engagement. The service partner’s expertise in evidence-based approaches to chronic care management has helped them maintain strong patient retention, consistently billing nearly three quarters of their patients every month.

Next Steps
Physician practices can realize financial, operational efficiency and patient satisfaction rewards by implementing chronic care programs. But they must commit resources—human and/or financial—to build a program that will deliver a substantial return on investment. Doctors’ groups should first inventory in-house resources, from clinician and staff bandwidth to the level of buy in and commitment the program can count on. Focusing on the key factors of enrollment and retention, practices can then decide whether insourcing or outsourcing the program is the best path forward.

Steven Wegner, MD, JD is the President of Community Physician Network of North Carolina, composed of nearly 1,000 independent primary care physicians, and Chief Medical Officer of Smartlink Health. He has worked in population health for 18 years. His broad experience includes serving as Chairman, Chief Medical Officer, and Chief Innovations Officer for the award-winning Community Care of North Carolina (CCNC) program.

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