JAMA Forum: Jump-starting Chronic Care Management Services

By Andrew B. Bindman, MD, and Donald F. Cox, PhD, MS

A little over a year ago, on January 1, 2015, Medicare implemented a chronic care management (CCM) billing code. This code, which pays an average of $42, can be billed once a month when a practitioner provides at least 20 minutes of CCM services to a patient with 2 or more chronic conditions.

The CCM services include the monitoring of a beneficiary’s care plan, the provision of access 24 hours a day, 7 days a week, to clinical staff who can retrieve information from the beneficiary’s electronic health record even when the office is closed; management of a beneficiary’s care transitions; and coordination with other clinicians, hospitals, and others who provide clinical services.

This payment code is Medicare’s first effort to pay for a service that can be provided entirely without a face-to-face visit. The billable time is for activities such as telephone communication with a beneficiary, reviewing the patient’s medical records and test results, and consultation and exchange of health information with other practitioners.

Although the medical community endorsed Medicare’s adoption of the CCM code, there have been concerns from the outset that several requirements in the payment rule would limit its uptake. One of the biggest concerns is that beneficiaries receiving this service are subject to Medicare’s standard 20% copayment fee (approximately $8 for each time this service is billed). Concerned that Medicare beneficiaries might not understand why they were receiving a bill for copayment when they had not seen their practitioner for a face-to-face visit, Medicare requires that a practitioner obtain consent from a beneficiary prior to first billing for this service.

Physician groups expressed concern that the requirement for around-the-clock availability to a practitioner with access to an electronic health record that meets meaningful use standards could also limit the ability of rural clinicians and others practicing in small groups to meet the requirements for billing. The medical community has also expressed interest in establishing additional billing codes, with varying payments for CCM services that would reflect beneficiaries’ different levels of need.

Slow Adoption

The early experience with the CCM billing code confirms that adoption has been slow. Data available through the Office of the Assistant Secretary for Planning and Evaluation indicate that through the first 9 months of 2015, Medicare paid CCM claims for just more than 200 00 beneficiaries. This represents approximately 1% of the estimated 20 million Medicare fee-for-service beneficiaries who have the requisite minimum of 2 chronic conditions and who make an office visit within a 1-year period. There has been a steady increase of approximately 20 000 new beneficiaries billed for CCM each month, but because not all beneficiaries who are receiving these services are being billed for them each month, the total number of monthly claims is rising more slowly. By September 2015, the monthly total number of beneficiaries for whom Medicare was billed for this service reached just less than 100 000.

Looking at this from the practitioner’s perspective, approximately 6000 physicians and an additional 800 nonphysicians have billed the CCM code at least once. This is rising by approximately 500 practitioners per month. Although only 30% of Medicare physicians (182 782 of 608 378) are trained in a primary care specialty, they represent 88% of the physicians who bill for CCM services.

About 90% of the practitioners who bill for any services in the Medicare program are in urban areas, and this pattern holds for practitioners who bill for CCM services. Surprisingly, the 27% of Medicare physicians who practice in small groups (1-5 physician practices) are disproportionately more likely than Medicare physicians in larger practices to bill for CCM services, billing for 33% of CCM services. The 37% of Medicare physicians in the largest groups (100 or more physician practices) are disproportionately less likely to bill for CCM services, billing for only 16% of CCM services.

The trajectory for the adoption of the CCM code appears to be mimicking the slow uptake of Medicare’s transitional care management code. Medicare adopted the transitional care management code on January 1, 2013, to incentivize practitioners to furnish transitional and care coordination activities outside of a face-to-face encounter in combination with an office visit within 1 to 2 weeks following a hospital or nursing facility discharge. In the first year of its adoption, practitioners billed Medicare for transitional care services for about 1% of eligible events; billing for this service has since grown at a rate of about an additional 2% of eligible events per year.

Additional Steps

Congress, with encouragement from its Medicare Payment Advisory Commission (MedPAC), has indicated an interest in taking additional steps to improve the care and the value of Medicare expenditures for beneficiaries with chronic conditions. In 2015, it included a provision within the Medicare Access and CHIP Reauthorization Act (MACRA), which codified payment for CCM services in Medicare.

In addition, a bipartisan working group within the Senate Finance Committee issued an options paper in December 2015 asking for public comment on a series of proposals to align Medicare payment with the needs of beneficiaries with chronic conditions. Among the suggestions were proposals to increase the uptake of CCM services by eliminating beneficiary copayments for the service and by establishing new CCM payment codes, which reflect differences in the intensity of the services that are provided. The options paper elicited 327 public comments, which the Finance Committee states will be considered as it moves forward with legislation.

The specialty pattern of the early adoption of CCM reflects the central role of primary care practitioners in delivering these services, but the low rate of participation suggests that the payment policy is in need of modification. MedPAC, which has historically had a significant amount of influence in shaping Medicare legislation, has advised Congress to eliminate beneficiaries’ copayment requirements for CCM services and to link Medicare’s payment for CCM services with an investment in primary care.

To simplify the billing process and to ensure that primary care practitioners have a dependable flow of funds to support the delivery of CCM services outside of face-to-face encounters, MedPAC recommends that payment for them be changed from fee-for-service to capitated primary care payment, based on the assignment of a beneficiary to a specific practitioner. Such an approach could also help to ensure a sufficient concentration of beneficiaries receiving the service within a practice.  Investigators who have modeled the availability of funding for CCM services have determined that from a business perspective, a practice needs to collect payment for these services from more than 100 patients to recoup up-front staffing and related costs.

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The findings and views expressed in this article are those of the authors and do not necessarily represent the views of the Office of the Assistant Secretary for Planning and Evaluation or the US Department of Health and Human Services.

About the authors:

Andrew B. Bindman, MD (Image: Ted Grudzinski/AMA)

Andrew B. Bindman, MD (Image: Ted Grudzinski/AMA)

Andrew Bindman, MD, is professor of medicine, health policy, epidemiology and biostatistics at University of California, San Francisco (UCSF). He is the founder and director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy, and a member of the National Academy of Medicine.

 

 

 

 

 

Donald F. Cox, PhD, MS

Donald F. Cox, PhD, MS

Donald F. Cox, PhD, is a senior economist in the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the US Department of Health and Human Services. Prior to joining ASPE, he worked at the Physician Payment Review Commission (predecessor of MedPAC), the Federal Trade Commission, the Departments of Labor and Defense, and several private sector consulting firms.  He holds an MS and PhD in economics from the University of Maryland, College Park.

 

 

 

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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