Introduced by the Centers for Medicare and Medicaid Services (CMS), chronic care management refers to services delivered under the CMS CPT code 99490 that involve preventative, “non-face-to-face-care” for qualifying patients with chronic health conditions.
The idea is that if healthcare providers can communicate with patients between visits–both respond to patient calls and check on patients to monitor adherence–patient care would improve and costs would come down for the overall system in the form of fewer hospital admissions and emergency room visits. Of course, for medical practices to embrace the service, they would have to be paid for it–the central element of CPT 99490 is that it reimburses practices that spend at least 20 minutes of remote contact per month.
Can it be profitable? Well, it’s early. An Annals of Internal Medicine study showed that a practice with 2,000 Medicare patients could generate more than $75,000 net revenue per full-time physician if half of their eligible patients enrolled in chronic-care management. They calculated that if a practice hired a registered nurse to work full-time on chronic care management, it would need to enroll at least 131 Medicare patients to break even. If the practice hired a licensed practical nurse, they would need to enroll 76.
What does it take to deliver chronic care management? One practitioner hired a dedicated registered nurse for the program, two licensed practical nurses, and a clerk to join a five-doctor and six-nurse practitioner practice. The new staff started making follow-up calls, monitoring patient-care plans, reviewing test results, and consulting with the patients’ other providers and caregivers. The practice estimates it needs at least 200 patients accessing the service per month to break even.
The care-management requirements include obtaining patient consent, recording data in a standardized format, and creating a care plan with an expected outcome, measurable goals, and strategies to manage symptoms and medication. Some believe the medical home care practices are at an advantage when it comes to chronic care management, as they already perform much of these services and have a patient base that is accustomed to home-based healthcare.
Critics of the code as it exists say that the detailed documentation required has been a turn-off to practices and see it as just one more example of medical bureaucracy getting in the way of healthcare delivery. Others like the idea but have pointed out that the system is out of sync with current certified electronic health record (EHR) products, which aren’t designed for home visits. The use of certified EHR products is required for most services in CPT 99490.
Awareness may be part of the problem. In its first year, only doctors billed under CPT 99490, far short of expectations. A Smartlink survey of 300 primary-care physicians found that two-thirds of them were unaware of the program or unfamiliar with its details. Another survey by PYA and Enli Health found that 26 percent of eligible providers have already launched CCM programs and another 23 percent plan to do so in the next 12 months. These early adopters, however, report struggling with physician engagement, patient education, efficient processes and regulatory compliance. Apparently, of those that know about chronic care management, there is interest.
Many were hoping that CMS would simplify CPT 99490 requirements for 2016, but that hasn’t happened. Still, others are certain that the market will develop systems and technology that will make chronic care management both medically successful and economically feasible. As new products come online and services become standardized among providers, adoption rates will grow and costs will shrink.
But the detailed documentation needed has led to criticism that chronic-care management is just another paperwork-generating government program.