Chronic Care Management

  This article is a part of our remote care series. We define remote care to be any form of care where the provider and patient are not in the same place. It includes many components such as chronic care, remote patient monitoring, mHealth etc. Remote care has risen in popularity over the years because of the ubiquity of technology, accelerated innovation, and new regulations.

  Last article, we covered remote patient monitoring. It was important to begin with remote patient monitoring because it has broader applications than chronic care.

  The applications of remote patient monitoring are many, which go beyond the treatment of chronic diseases. It can include post-acute care as well, and also any other shorter forms of care which includes the monitoring of physiological data.

  For chronic care however, supplementing the program with remote patient monitoring is pretty common. So while chronic care depends on remote patient monitoring, remote patient monitoring does not depend on chronic care. 

That being said, chronic care is extremely important to the healthcare system for the following reasons:

  More than half of US adults have at least one chronic condition,and 86% of all healthcare costs can be attributed to chronic diseases. 

  The burden of chronic care is not simply because of people’s increased life expectancies, but the actual prevalence of such chronic diseases is growing amongst the population. 

  Direct costs of chronic care include longer and more frequent hospitalizations. Indirect costs include the loss of education and job opportunities. Combined together, the total cost is estimated to be $3.7 trillion each year, almost 20% of USA’s GDP!

How Chronic Care Programs Fit in

Chronic Care Programs

  Strictly speaking, chronic conditions are not contagious, and don’t fit the bill of an epidemic. But it is labeled as an invisible epidemic by some. Indeed, during the COVID-19 pandemic, it is the combination of the virus with pre-existing comorbidities that are causing the overwhelming majority of deaths in USA and the world over.

  The whole world is shifting to more value based systems, be it private healthcare systems or public healthcare systems. This value is reflected in many ways. 

  Instead of just having a fee for service (FFS) system, the end compensation is being determined by performance. Then, there is the capitation model, where one gets a certain dollar amount per patient, so it is imperative to maintain the health of that patient or risk suffering a loss. Also,separate programs are being created where many services are lumped together to treat a common episode of health.


  All such systems add more value because they make the healthcare organization, physicians and other healthcare professionals more accountable for the care they provide. 

  Sometimes though, lumping several services together negates the seriousness and intensity of effort and skills that it required to address a particular health issue. Some of these issues can be real plagues to the system. In such instances, separating payment to address that one problem is a great favor to all parties involved. It is a form of value addition.

  One such value addition was the introduction of the Chronic Care Management program by Centers of Medicare & Medicaid (CMS) services back in 2015. 

  It has brought the issue of chronic diseases to the forefront, and has created ripples in how healthcare is done at large.

We cover three ways in how chronic care programs have changed healthcare:

More Value based than Procedural

  In an effort to shift from volume-based care to value-based care, a chronic care program looks to add value to a patient’s life by eliminating the need for travel which translates to time and monetary cost to the patient. Monthly communication is emphasized. A mission control approach is adopted which keeps tabs on the patient from afar.

  Besides genetics, a lot of health comes down to the environment, circumstances and actions taken by the patient. Keeping someone healthy therefore takes continuous effort, but it still costs the system less than expensive procedures.

Spillover effect on the rest of the healthcare: The rise of more outpatient centers or home based care where possible. The cut down of unnecessary admissions and overnight hospital stays.

Reigning a Tighter Control over Health

  The patient is not left to fend for themselves and cycled through the healthcare system in different inpatient and outpatient centers. Their care is better coordinated with multidisciplinary staff such as primary care physicians, specialists ,nurses, pharmacists, social workers, caregivers, etc. 

Spillover effect on the rest of the healthcare: The rise of patient-centric healthcare. Quicker adoption of the electronic healthcare system, and the ease of accessibility of this information for all parties involved while maintaining all the privacy protocols.

Marrying Management with Care

  Often, chronic patients are unable to perform certain activities adequately which may hamper their adherence to the care plan. Social support may be required. Any knowledge or facilitation of community services go a long way. So it’s as much about the management of the patient, as it is about providing care to the patient. Holding them accountable is key, but it is also a full time responsibility and requires dedication.

Spillover effect on the rest of the healthcare: Many operational positions are created which put a great deal of emphasis on the coordination or case aspect of healthcare. Caregivers and family members have had to face the brunt of duties for a long time now, but technology is increasingly stepping in, where access to a variety of resources and information regarding the case is made available on the phone. 

Trends in the Covid Era

Chronic Care During Covid

COVID-19 has no doubt promoted a remote first approach to healthcare. The American Journal of Managed Care has endorsed the use of digital virtual care tools and clinical registries to cater to the chronic patient population. 

  As COVID cases got the utmost priority, some of the in-person aspects of long term chronic care such as scheduled follow up visits after a procedure are postponed, and this is expected to have negative ramifications on the quality of those cases. 

But it has nothing to do with the clinical or cost efficiency of remote chronic care, but more to do with the overall attention and resources that the pandemic has been sucking up.

Generally, the case for chronic care adoption continues to grow. 

Greater Willingness to Shift to Remote Care

  In a survey of 1010 patients, almost two-thirds of patients said that the remote patient monitoring device would need to be equally or a little more effective than their current regimens. But this willingness of patients decreased when the wearable or monitoring device was said to be intrusive. 

  We see how far the cultural acceptance to remote tracking has come. Consumer gadgets like the Fitbit or Apple Watch have definitely expedited this. People are willing to shift to remote forms of care as long as there is no drop off in the health outcome. But their likelihood to go remote depends on the user-friendliness of the monitoring tech. 

  It is very understandable. It is why connected health apps are popular among patients, with 80% of patients saying they use such apps. 

  But 70% of patients vouch for the effectiveness of condition specific mHealth devices such as pacemaker, blood glucose monitor and pulse oximeters. This number drops to 28% of those who just use a general app. So  it’s a tricky act to balance attachment and ease of use.

  Things are always being miniaturized which makes the devices less clunky, but as far as the frequency of readings go, it would be ideal if the device was placed permanently on the patient’s body, such as a patch, an armband, a ring, or a watch. It would be in the truest sense of the word, “real-time reading” or 24/7 reading.  But this then reduces the freedom of the patient to be without any such commitments at all. They might just prefer to have the device be separate and use it when it’s time to do so.

Greater Recognition From Payers

  Some chronic care management are enabled with technology right from the start. Humana Care Support is one such program which will use data to create an integrated personalized care experience for its patients that includes a multidisciplinary team. 

  Besides the government, the many private insurance companies are some of the biggest payers of treatment related to chronic care. So it is in their interest to reduce hospital utilization wherever possible. They see the value in the ability to remotely monitor a patient’s vital signs at regular intervals.

How to To Enroll a Patient

Enrolling Patient for Chronic Care

 Clearly, there are patients who need chronic care. Two-thirds of Medicare beneficiaries had multiple chronic conditions a decade ago, and that portion has only increased throughout the years. 

  Despite this, it is reported that less than 10% of eligible beneficiaries are actually enrolled in a program used to treat chronic diseases.

  Examples of chronic diseases that are treated by chronic care programs include some of the biggest killers and cost drivers in the system. There are as much as 60 chronic diseases listed by CMS. We’ve listed the major chronic diseases in the order of the annual costs to treat them. Each figure is rounded to the nearest billion. 

They are as follows:

Heart Failure and Stroke- $351 Billion

Diabetes- $237 Billion

Alzheimer’s Disease- $215 Billion

Obesity- $210 Billion

Cancer- $150 Billion

Arthritis- $140 Billion

  But as discussed earlier, the uptake for CCM has not been that great. There is clearly a missed opportunity to better educate and enroll patients who might be needlessly suffering from uncoordinated care. 

  The first step is to identify patients who might be eligible for the program. Secondly, there must be an outreach to educate them about the service that is available to add value to their lives. In this stage, it’s also possible that they can approach you and inquire about such a program. If they agree to the program, they can be enrolled. Without gaining prior consent, it’s not possible to begin any form of chronic management program.

  Written or verbal consent should be documented to enroll in the program. It applies to all of the following chronic care options we’ll be covering in the subsequent sections.

  The patient must be notified that only one physician can provide these services and be paid for it a single calendar month. They should also know that such services are voluntary, and the patient has the right to stop at any time.

  A comprehensive care plan must be developed for the patient of which they should receive a copy. The comprehensive care plan includes the current health diagnosis and goals to manage these diagnoses. It allows the health care provider to coordinate care between hospitals, clinics and pharmacies if necessary. It allows them to educate the patient on their condition and course of treatment. 

A face-to-face meeting is required to do or get started on all the steps mentioned above. 

Though the requirement for a prior patient-provider relationship was waived during the public health emergency because of COVID-19, the chronic care program was never classified as telehealth. So an established relationship is mandatory in this regard.

Also, it’s a big commitment for both the patient and the provider to embark on such a care journey. So it only makes sense that the parties involved are familiar with each other. 

  The Annual Wellness Visit (AWV) is a common introductory path to chronic care. The AWV is an annual appointment with the primary care provider to create or update a personalized prevention and perform a Health Risk Assessment. 

HCPCS G0438- This code is used for the initial AWV where patients are eligible after the first 12 months of medicare coverage.

HCPCS G0349- This code is used for all subsequent AWVs after the first one. There must be a mandatory gap of at least 12 months between each AWV.

Options Available For Treatment

Chronic Care Treatment Options

  To understand all the latest rules for operating a program used to treat patients with chronic diseases, one should always refer to the latest Medicare Physician Fee Schedule Final Rule.

  We’ve gone over the 2021 Final Rule, to bring you this update.

  The first fork in the road when it comes to thinking about the program is the number of chronic conditions the patient has. 

If it’s one chronic condition, then they are eligible for the Principal Care Management (PCM) Program.

The Principal Care Management program began in 2020 to treat those patients with a single chronic condition. 

There are some key differences that sets PCM apart from its more popular chronic care counterpart, CCM (Chronic Care Management).It is commonly used to treat patients after an exacerbation of condition or hospitalization.  Thus one can sense that there is an anticipated date where the patient will return to normalcy. So it is more to do with treating that specific disease rather than managing the total care of the patient, which lies more within the realm of CCM. 

  Also, CMS says that the specialist is expected to bill for such services, instead of the primary care physician who usually bills for CCM. Note that other qualified healthcare professionals can bill for CCM as well. We’ve covered this in the first part of our remote care series. Please read the section Who is Allowed to Bill?

HCPCS G2064- Requires at least 30 minutes of physician or other qualified professional health care professional time per calendar month

HCPCS G2065- Requires at least 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per month

If it’s more than one chronic condition, then they are eligible for the Chronic Care Management Program. 

Before enrolling anyone into CCM, the following criteria must be:

  • Their chronic conditions should be expected to last at least 12 months or until the death of the patient. 
  • They should be at risk of death, acute exacerbation, decompensation or functional decline.
  • A comprehensive electronic care plan should be established and maintained.
  • They should have 24/7 access to care and health information. 
  • The provider must facilitate the transitions of care, if there is a need for it.

The next question one should ask is if the patient requires non-complex CCM or complex CCM, because there are different reimbursement codes available for each scenario.

For Non-Complex Care

CPT Code 99490- Requires at least 20 minutes of chronic care management services in a calendar month from clinical staff directed by a physician or other qualified healthcare professional. 

Chronic Care Management Services include:

  • Monthly phone calls or video calls
  • Performing medication reconciliation
  • Ensuring that the patient receives all recommended preventative services
  • Monitoring the symptoms
  • Create care plans (will include things such as medication list, diagnosis, monthly record of vitals signs, allergies, events like lab work, hospitalizations, lifestyle notes, identifying individuals responsible for all interventions, etc)
  • Follow up with the patient via phone
  • Face-to-face video calls
  • Providing educational or community resources
  • Mention health goals
  • Constant communication through a secure portal

CPT Code 99439- This code is used to cover for each additional 20 minutes of chronic care management services that is not covered by CPT 99490. It can be billed a maximum of two times a calendar month.

  Note that while the clinical staff may provide the service under the general supervision of a physician or qualified health professional, only the latter two may bill for it.

  There is also another code that is available to treat non-complex CCM. It was introduced in 2019 for those patients whose care had to be personally provided by a physician or qualified non-physician practitioner, and not the clinical staff.

CPT Code 99491- Requires at least 30 minutes of chronic care management services in a calendar month from a physician or other qualified healthcare professional. 

For Complex Care

Complex care requires the establishment, revision, implementation or monitoring of a care plan and/or moderate or highly complex medical decision making. The patient would also require more time each calendar month for treatment than non-complex care. It is why non-complex care codes and complex care codes cannot be billed concurrently in the same month. 

But remote patient monitoring codes can be billed with either complex care or non-complex care in the same month. It is treated as a different service, that enhances the value of either of those programs.

CPT Code 99487- Requires at least 60 minutes of complex chronic care management services in a calendar month from clinical staff directed by a physician or other qualified healthcare professional. 

CPT Code 99489- This code is used to cover for each additional 30 minutes of complex chronic care management services in a calendar month from clinical staff directed by a physician or other qualified healthcare professional. 

In Conclusion

State of Chronic Care Today

  Chronic care management has seen success, but it is not without its difficulties. In the covid-era, where the focus is ever greater on self preservation, and the culture is suited for remote health tech, it’s a good time to increase chronic care adoption, be it through PCM (1 chronic disease ) or CCM (2 or more chronic diseases).

  You may need staff dedicated to enrollment, as CCM programs do see heavy churn. There is copay involved which is a shock to some patients. So it is a continual effort to educate the patient on the value of the program, and keep them invested in their efforts to manage their health. Engagement is a two-way street, and it can absolutely be achieved with the cooperation of all involved in the care team. 

  When combined with remote patient monitoring, it’s a great mechanism for creating a virtual care space for patients inside their homes. Especially during emergency periods or for patients who have geographic barriers, it is a fantastic way to get the care that they deserve. There are some things that remain to be discussed however, such as treating behavioral health and managing care transitions. We’ll cover that in the 3rd part of this series on remote care. 

















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