CMS Encourages Chronic Care Management Through Policy, Reimbursement

As the health care industry moves from a fee-for-service world to a value-based one where providers take on more risk caring for entire populations, chronic care management (CCM) has become essential and increasingly critical to success. Providing high-quality care often necessitates additional resources to help patients navigate the fragmented world of subspecialists and imaging facilities, especially for frail, medically complex patients.

Recognizing the importance of chronic care services and disease management, CMS has taken several steps to incent health care providers to set up or improve their care management programs and processes. These include: 1) the creation of a care transitions program; 2) proposed payments for advanced care planning; and 3) reimbursement for non–face-to face care management through CPT code 99490. Many organizations are already managing care in these ways as a part of their mission, a pilot, or a way to improve quality. Now, CMS is stepping up and encouraging all organizations to do this work regardless of where they are in the transition to value.

Care Transitions Program
Created by the Patient Protection and Affordable Care Act (ACA), the Community-based Care Transitions Program (CCTP) seeks to improve the transition of care from the hospital to other care settings, improve care coordination and reduce readmissions for high-risk Medicare patients. In August 2015, the first Medicare-approved third party transitional care center opened. Through the center, registered nurses and nurse practitioners provide clinical care to patients who are at high risk for being readmitted for a period lasting up to 30 days post–hospital discharge. Needed services are coordinated and any questions the patient or their family may have are addressed. Transitional care programs will likely increase in number once their value is fully illustrated. While transitional care focuses on the 30-day period of readmission targeted by CMS, incentives for care coordination are likely to continue as a bridge to chronic care management.

Advanced Care Planning
CMS is also incenting providers to help manage patients’ advanced care and palliative care needs. In its proposed Physician Fee Schedule (PFS) rule for 2016, 2 new planning codes provide reimbursement to physicians or qualified professionals for having discussions with patients about and carefully planning their advanced care. For patients with chronic or severe illnesses, these discussions are extremely important to help them carefully weigh the risks and benefits of available treatments. Creating advanced care plans is one important aspect of palliative care, which is gaining momentum as a way of improving care and saving costs by decreasing utilization of unwanted and/or low-value medical interventions.

Chronic Condition Management
Data from CMS show that two-thirds of Medicare beneficiaries have 2 or more chronic conditions and one-third have 4 or more. Moreover, the sickest 5% of the population accounts for ~60% of health care spending. Coordinating care for these complex patients is often time consuming for providers, but it is critical to provide high-quality care, decrease overall costs, and ensure that patients are not being subjected to repeated or unnecessary tests and procedures.

Beginning in calendar year 2015, CMS began offering payment to providers for non–face-to-face care coordination for Medicare beneficiaries with multiple chronic conditions using CPT code 99490. It is likely that many providers were already offering these services without payment; now CMS is providing direct reimbursement above and beyond payment for evaluation and management codes or office visits.

Maximize Value by Focusing on Patient Segmentation, Provider Alignment
With these programs and proposals, CMS has recognized the difficulty in effectively providing value-based care and is incenting organizations to do so. For organizations still operating in a fee-for-service environment, CMS is offering support to help them bridge the gap to value-based payment with less risk. Organizations that have transitioned to a value-based world may be able to expand their programs to address a broader patient population.

Maximizing the value of these initiatives will require:

  • Patient segmentation
  • Provider alignment
  • Protocol development

Patient segmentation will be needed to identify those patients who will benefit the most from care coordination and chronic disease services. Segmentation methods vary in complexity and can include simple qualitative assessments of patients’ chronic conditions, their severity and other comorbidities to complicated proprietary systems that consider a wide range of patient data to identify patients. Whatever the method used, the goal is to find the patients most at risk of decompensation and exacerbations of their conditions. These patients should be the focus of care management efforts, to improve their quality of life and functionality, and to decrease avoidable utilization of health care services.

In addition to careful patient selection, organizations must consider how best to align with providers. This includes creating incentives for physicians and nurses to provide coordinated care and designing workflows to fit any new services and appropriate documentation into their work process.

Protocols should be developed so that physicians, nurses and practice staff know their responsibilities. In-house IT and EHR resources can be used to measure results and outcomes.

Consider CCM Across the System of CARE
CMS has taken an important step by recognizing the importance of CCM services in promoting better outcomes at reduced spending levels for our most challenging patients. Sg2 can help you get the most out of these initiatives. The Market Demand Forecast module on the Sg2 Analytics platform is a good starting point for patient segmentation. It can be used to identify high-volume chronic diseases in your market.

As US health care moves inexorably to a “value-based” environment, we believe there will be an increased focus on patients with multiple, chronic illnesses. Health care strategists should take a broad approach to their organizations’ capabilities to treat their sickest patients across their entire System of CARE. CPT code 99490 for CCM services offers one such opportunity, supporting a strategic approach to care for these medically complex patients.

Sg2 Consultants Jonathan Stricker, PhD, and Chad Giese contributed to this post.

Sources: CMS. Chronic Conditions Among Medicare Beneficiaries. Chartbook: 2012 Edition; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. September 17, 2014; Sg2 Analysis, 2015.

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