Medicare enrollees with two or more chronic conditions are eligible for chronic care management, which pays doctors to check in with these patients monthly. But the service did not take off.
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Medicare enrollees with two or more chronic conditions are eligible for chronic care management, which pays doctors to check in with these patients monthly. But the service did not take off.
John Moore/Getty Images
Carrie Lester looks forward to the phone call every Thursday from her doctor’s medical assistant, who asks how she’s doing and if she needs refills on her prescriptions. The assistant advises her on how to manage her anxiety and other health problems.
Lester credits the discussions with keeping her out of the hospital and reducing the need for clinic visits to manage chronic illnesses, including depression, fibromyalgia and hypertension.
“Just knowing that someone is going to check on me is comforting,” says Lester, 73, who lives with his dogs, Sophie and Dolly, in Independence, Kansas.
At least two-thirds of Medicare enrollees have two or more chronic health conditions, according to federal data. That makes them eligible for a federal program that, since 2015, has rewarded doctors who do more to manage their health outside of office visits.
But even though early research found that the service, called Chronic Care Management, reduced emergency room and inpatient hospital visits as well as overall healthcare spending, adoption has been slow.
Federal data from 2019 shows that only 4% of potentially eligible enrollees participated in the program, a figure that appears to have held steady through 2023, according to a Mathematica analysis. About 12,000 doctors billed Medicare under CCM in 2021, according to the latest Medicare data analyzed by KFF Health News. (Medicare data includes doctors who billed CCM each year at least a dozen times.)
For comparison, federal data shows that about 1 million providers participate in Medicare.
$62 per patient per month
Although the strategy failed to reach its potential, thousands of doctors increased their annual salaries by participating, and for-profit ancillary businesses sprung up to help doctors take advantage of the program. Federal data shows that about 4,500 doctors received at least $100,000 each in CCM compensation in 2021.
Through the CCM program, Medicare funds the development of a patient care plan, coordination of treatment with specialists, and regular contact with beneficiaries. Medicare pays doctors a monthly average of $62 per patient, for 20 minutes of work with each, according to industry companies.
Without this program, providers often have little incentive to spend time coordinating care because they cannot bill Medicare for such services.
Health policy experts say a multitude of factors limit participation in the program. Chief among them is that it requires doctors and patients to adhere. Physicians may not have the ability to regularly monitor patients outside of office visits. Some also worry about meeting Medicare’s strict documentation requirements for reimbursement and are hesitant to ask patients to join a program that may require a monthly copay if they don’t have an additional policy.
“This program had the potential to have a big impact,” says Kenneth Thorpe, a health policy expert on chronic diseases at Emory University. “But I knew it was never going to work from the start because it was poorly organized.”
He said most doctor’s offices are not equipped to monitor patients at home. “It takes a lot of time and it’s not something doctors are used to doing or don’t have time to do,” Thorpe says.
For patients, the CCM program aims to expand the type of care offered under traditional, fee-for-service Medicare to match the benefits they can receive – at least in theory – through Medicare Advantage, which is administered by private insurers.
But the CCM program is open to Medicare and Medicare Advantage beneficiaries.
The program also aimed to increase the salaries of primary care doctors and other physicians who are paid significantly less by Medicare than specialists, says Mark Miller, former executive director of the Medicare Payment Advisory Commission, which advises Congress. He is currently executive vice president of Arnold Ventures, a philanthropic organization focused on health policy. (The organization also funded KFF Health News.)
No “easy money”
Despite the lure of extra money, some doctors were discouraged by the program’s upfront costs.
“It may seem like easy money for a medical practice, but it’s not,” says Dr. Namirah Jamshed, a physician at UT Southwestern Medical Center in Dallas.
Jamshed says the CCM program was cumbersome to implement because his practice was not accustomed to documenting time spent with patients outside of the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice began being reimbursed by the program.
Only about 10 percent of the practice’s Medicare patients are enrolled in CCM, she said.
Jamshed says his firm was approached by private companies looking to do the work, but the firm objected because of concerns about sharing patient health information and the cost of retaining the companies. These companies can take more than half of what Medicare pays doctors for their CCM work.
Dr. Jennifer Bacani McKenney, who with her father runs a family practice in Fredonia, Kansas, where Carrie Lester is a patient, says the CCM program has worked well.
She says having a system to stay in touch with patients at least once a month has reduced their use of emergency rooms, including for some who were inclined to visit for non-urgent reasons. , such as running out of medication or even feeling alone. CCM funding allows the practice’s medical assistant to regularly call patients to check in, something he previously couldn’t afford.
For a small practice, having a staff that can generate additional revenue makes a big difference, McKenney says.
Although she estimates that about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants to receive calls, she says.
Although the program has attracted interest from internists and family doctors, it has also paid hundreds of thousands of dollars to specialists, such as those in cardiology, urology and gastroenterology, according to the analysis of KFF Health News. Primary care physicians are often seen as those who coordinate patient care, making payments to specialists notable.
A 2017 Mathematica-funded study found that the CCM program saved Medicare $74 per patient per month, or $888 per patient per year, primarily due to a reduction in the need for hospital care.
The study cites contractors who are unhappy with attempts to outsource CCM work. “Third-party companies are turning this into a racket,” one doctor quotes in the study, noting that the companies employ nurses who don’t know the patients.
Nancy McCall, a researcher at Mathematica and co-author of the 2017 study, says doctors aren’t the only point of resistance. “Patients may not want to be bothered or asked if they are exercising, losing weight, or watching their salt intake,” she says.
How Outsourcing Works
Still, some physician groups say it’s practical to outsource the program.
UnityPoint Health, a large integrated health system based in Iowa, tried to manage chronic care on its own, but found it administratively cumbersome, says Dawn Welling, chief nursing officer of the UnityPoint clinic.
Over the past year, she contracted with a Miami-based company, HealthSnap, to register patients, have its nurses make check-in calls each month and help with billing. HealthSnap helps manage the care of UnityPoint Health’s more than 16,000 Medicare patients, a small fraction of its Medicare patients, which includes those enrolled in Medicare Advantage.
Some doctors were nervous about sharing patient records and saw the program as a sign that they weren’t doing enough for patients, Welling says. But she says the program has been helpful, especially for many enrollees who are isolated and need help changing their diet and other behaviors to improve their health.
“These are patients who call the clinic regularly and have needs, but not always clinical needs,” Welling says.
Samson Magid, CEO of HealthSnap, says more doctors have started participating in CCM since Medicare increased pay in 2022 for 20 minutes of work, from $41 to $62, and added billing codes for extra time.
To ensure patients answer the phone, caller ID indicates that HealthSnap calls come from their doctor’s office, not where the company’s nurse is located. The company also hires nurses from different regions so they can speak dialects similar to those of the patients they work with, Magid says.
He says some enrollees have been in the program for three years and many could remain enrolled for life, meaning they can bill patients and Medicare long term.
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the major operating programs of KFF — the independent source for health policy research, polling and journalism.
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