Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

O’Malley, Ann S.; Sarwar, Rumin; Keith, Rosalind E.; Balke, Patrick; Ma, Sai; McCall, Nancy

doi:10.1007/s11606-017-4134-7

Cited by 39 publications

(39 citation statements)

References 10 publications

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“…Beginning in CY 2017, three temporary G-codes, G0502, G0503 and G0504, became billable 39 . These codes, which were designed similarly to Medicare’s CY 2015-initiated, time-based Chronic Care Management (CCM) codes 40,41 , reimbursed treating (billing) practitioners for the cumulative time that they and their staff spent managing patients in the evidence-based CoCM model over the course of a calendar month. Briefly, G0502 was used for the first seventy minutes in the first month for behavioral health care manager activities (with the stipulation that the care manager was working with a psychiatric consultant).…”

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

“…The CCM model, like CoCM, is intended to enhance care continuity, care coordination, and ongoing management for patients with chronic conditions 41 . Patients are eligible for CCM if: (1) they have two or more chronic conditions expected to last at least twelve months, (2) these conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and (3) a comprehensive care plan is established 45 .…”

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

“…Patients are eligible for CCM if: (1) they have two or more chronic conditions expected to last at least twelve months, (2) these conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and (3) a comprehensive care plan is established 45 . Medicare’s CCM codes, which were specifically designed to reimburse for these services (outside of face-to-face clinical encounters), were billable for all beneficiaries who met criteria 41 . In a 2017 study, O’Malley and colleagues found that, during the first fifteen months of the new CCM payment policy, only about 4.5 percent of eligible non-institutional primary care providers billed Medicare for this service 41 .…”

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

“…Medicare’s CCM codes, which were specifically designed to reimburse for these services (outside of face-to-face clinical encounters), were billable for all beneficiaries who met criteria 41 . In a 2017 study, O’Malley and colleagues found that, during the first fifteen months of the new CCM payment policy, only about 4.5 percent of eligible non-institutional primary care providers billed Medicare for this service 41 . The same study also noted some of the most common barriers to code uptake, which included Medicare-stipulated patient cost-sharing, perceived inadequate reimbursement, requisite workflow modifications and inadequate health information capabilities 41 .…”

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

See 3 more Smart Citations

Financing for Collaborative Care—a Narrative Review

Carlo

Unützer

Ratzliff

et al. 2018

Curr Treat Options Psych

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Purpose of Review Collaborative care (CoCM) is an evidence-based model for the treatment of common mental health conditions in the primary care setting. Its workflow encourages systematic communication among clinicians outside of face-to-face patient encounters, which has posed financial challenges in traditional fee-for-service reimbursement environments. Recent Findings Organizations have employed various financing strategies to promote CoCM sustainability, including external grants, alternate payment model contracts with specific payers and the use of billing codes for individual components of CoCM. In recent years, Medicare approved fee-for-service, time-based billing codes for CoCM that allow for the reimbursement of patient care performed outside of face-to-face encounters. A growing number of Medicaid and commercial payers have followed suit, either recognizing the fee-for-service codes or contracting to reimburse in alternate payment models. Summary Although significant challenges remain, novel methods for payment and cooperative efforts among insurers have helped move CoCM closer to financial sustainability.

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Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

Section: Medicare Fqhc and Rhc Fee-for-service Reimbursementmentioning

confidence: 99%

See 2 more Smart Citations

Financing for Collaborative Care—a Narrative Review

Carlo

Unützer

Ratzliff

et al. 2018

Curr Treat Options Psych

View full text Add to dashboard Cite

show abstract

“…1 The investigators conducted semi-structured interviews of providers who bill the Centers for Medicare and Medicaid Services (CMS) for CCM, those who do not, and professional society representatives in order to elucidate the perceived facilitating factors, barriers, successes, and failures of the federal payment policy for the important disease management work done outside of office visits. Their findings reveal critical limitations in the CCM payment policy, even after the 2017 amendments.…”

mentioning

confidence: 99%

Capsule Commentary on O’Malley et al., Providers’ Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

Hoffman

2017

J GEN INTERN MED

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T his qualitative study by O'Malley et al. explores the current state of chronic care management (CCM) in a variety of practice settings. 1 The investigators conducted semi-structured interviews of providers who bill the Centers for Medicare and Medicaid Services (CMS) for CCM, those who do not, and professional society representatives in order to elucidate the perceived facilitating factors, barriers, successes, and failures of the federal payment policy for the important disease management work done outside of office visits. Their findings reveal critical limitations in the CCM payment policy, even after the 2017 amendments. 2 For context, we know that CCM, done right, can decrease hospitalization and ED visits over time, with an estimated $101-per-participant reduction in Medicare spending. 3 We also know that proper implementation of CCM, like anything else, takes time and money. Reimbursement for CCM by CMS is a step in the right direction, but uptake in the early years of the policy is incredibly low, with fewer than 5% of all eligible providers billing CCM. This study sheds light on why.The study findings are limited by the small number of nonbilling providers interviewed, but the results highlight the limitations of the CCM policy itself. Documentation burdens and active billing (as opposed to per-member/per-month payments used in patient-centered medical home models) create barriers to entry for providers. Worse, patient eligibility restrictions and coinsurance payments are barriers for patients. We know from the 40-year old RAND health insurance experiment that patient cost sharing leads to decreased utilization of even highly effective services, 4 and cost sharing was indeed highlighted as a barrier for those without supplemental coverage. One in seven Medicare beneficiaries have no supplemental coverage, 5 and they are disproportionately black, poor, and disabled. Not only is the coinsurance ineffective at achieving the goal, but it contributes to health inequity.Taken together, these findings suggest that further improvements in the CCM payment policy that reduce barriers to uptake and ensure best practices have the potential to reduce costly utilization, improve outcomes, and save money, the holy grail of healthcare value.

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Challenges in Implementing Personalized Care Planning—Reply

Edwards

Dorr

Landon

2017

JAMA

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To the Editor Dr Edwards and colleagues 1 asked if personalized care planning can improve primary care. Their discussion belies the complexity of implementing their 3 essential components without an underlying organizational transformation. Personalized care planning is predicated on patientcentered care, necessitating cultural transformation toward a biopsychosocial perspective, seeing the patient as a person and the physician as a person, each sharing power and responsibility, and a therapeutic alliance 2 -features often at odds with a disease-focused culture of medicine.First, optimizing the management of chronic disease will be difficult when patient and clinical goals are unaligned. An impoverished patient with uncontrolled diabetes may prioritize rent over dietary changes. A patient who is alcoholic may be disinterested in stopping drinking because he or she values social interactions. Patients' social needs can undermine self-management of chronic disease. Personal care planning is a tool to understand what really matters to a patient because these social determinants of health drive self-management. Clinicians will need to share power with patients by incorporating each patient's knowledge of their social circumstances with the health care professional's clinical expertise. This will yield not only a therapeutic alliance but can improve adherence and clinical outcomes, thereby optimizing disease management. 3 Second, patient goals are often secondary to clinical and organizational objectives. Devoting time in an encounter to know the patient as a person, with unique social circumstances, is central to developing a personalized care plan. Yet clinicians are incentivized to complete specific tasks in a clinical encounter (eg, hypertension control). They are rarely rewarded for spending time talking about a patient's social needs. Furthermore, clinicians who do identify social risks are often left in a siloed system with ad hoc resources, disconnected from the community. 4 Third, as Edwards and colleagues noted, a centralized record is necessary but insufficient. Electronic medical records were designed for billing and for documentation of clinical conditions; many currently lack the ability to capture a patient's perspective. Even with documentation, other clinicians could undermine an exemplary personal care plan by focusing solely on developing plans in accordance with more traditional, disease-focused plans.Accomplishing personalized care plans thus requires an organizational infrastructure that actually disrupts traditional medical care. 5 For personal care plans to truly take hold, the health care system, organization, and culture must support this cultural transformation. Thus, as health care organizations begin to ask primary care clinicians to engage in personal care planning, they must not only put into place structures to support it but also work toward shifting the culture of care.

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Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

Abstract: Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.

Cited by 39 publications

References 10 publications

Financing for Collaborative Care—a Narrative Review

Financing for Collaborative Care—a Narrative Review

Capsule Commentary on O’Malley et al., Providers’ Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study

Challenges in Implementing Personalized Care Planning—Reply

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