By Insaf Mohammad, Pharm.D., PGY2 pharmacy resident, Detroit Medical Center
The number of patients with chronic conditions and their contribution to healthcare expenditures in treating these conditions continues to grow.1 In 2010, over two thirds of Medicare beneficiaries had two or more chronic conditions. Of those, 14 percent had six or more chronic conditions.1 Such patients are responsible for a disproportionate number of hospitalizations, readmissions and total Medicare spending.1 Care of patients with chronic conditions, however, remains suboptimal. An analysis of the quality of healthcare delivered in the United States revealed that patients with chronic conditions received less than 55 percent of recommended care.2 Among geriatrics, a more vulnerable group of patients, less than 50 percent of recommended care was received.2 Therefore, a considerable potential to improve outcomes exists if this gap in care can be bridged.
What is Chronic Care Management (CCM)?
The management of chronic disease states is complex and typically requires ongoing care delivered using multifaceted strategies. Historically, reimbursement in fee-for-service models for care coordination, education and counseling has been limited, particularly for non-face-to-face care.3 In an attempt to address the existing gaps in care, as of Jan. 1, 2015, Medicare began reimbursing non-face-to-face chronic care management (CCM) services provided to Medicare beneficiaries with at least two chronic conditions. The CCM service incentivizes the provision of continuity of care and comprehensiveness.4-6 This is achieved via care coordination services, medication management and management at care transitions.4,5 Reimbursement is available for patients who meet eligibility criteria and are provided with at least 20 minutes of non-face-to- face care coordination per month.
Both Medicare and the American Society of Health-System Pharmacists have endorsed pharmacists as “clinical staff” eligible to provide CCM services and billing under the supervision of a provider.7 The payment for CCM is approximately $40 billed under the Current Procedural Terminology (CPT) code 99490 once per calendar month, with higher billing codes available for time spent on more complex CCM.7,8
Design and Implementation of a CCM Program
Although the Centers for Medicaid and Medicare Services (CMS) have not described a formalized approach for provision of CCM services, the pharmacy team at the Rosa Parks Wellness Institute for Senior Health (RP-WISH) in the Detroit Medical Center created a service model that meets the requirements they have set (Figure 1). At RP-WISH, electronic medical record (EMR) capabilities were used to create a dashboard of patients meeting eligibility criteria for service reimbursement. Such patients include those with at least two chronic conditions. The EMR dashboard includes several pieces of information, such as most recent HgbA1c values, blood pressure and hospitalizations within the past 30-days.
Once enrolled in the program, the CCM dashboard is used to prioritize which patients should be provided with CCM services first each month. We do this by providing services to patients most out of range from their goal HgbA1c or blood pressure. A member of the pharmacy team then provides a phone call focusing on the patient’s chronic care needs. This includes medication adherence, lifestyle education, vaccination recommendations and reinforcement of healthcare-related goals (i.e., HgbA1c, blood pressure, LDL). If the patient is unreachable by phone, a chart review is conducted. A summary of the phone call or chart review, including specific steps to attain their goals, is then mailed to the patient. Once the CCM encounter is complete, the details of the encounter are documented in the EMR and then sent to the primary care physician for co- signature.
Figure 1: CCM service workflow at the RP-WISH
The Impact of CCM
The Rosa Parks Wellness Institute for Senior Health (RP-WISH) is a designated patient-centered medical home located in the Detroit Medical Center, providing comprehensive primary and specialty care to over 3,000 patients 60 years of age and older. In August 2015, the pharmacy team at the RP-WISH implemented a CCM program that has enrolled over 150 patients to date. Our team includes a pharmacist, a PGY2 ambulatory care pharmacy resident and rotating students. We anticipate that the provision of CCM services will enhance the quality of care that we, as the healthcare team, provide to our patients. This non-face-to-face communication in between clinic visits reinforces medication adherence, improves coordination of care and enhances our relationship with patients. Overall, we anticipate that CCM will lead to positive health and economic outcomes in the ambulatory care setting.
- Chronic Conditions Among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012:1-30. https://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. (Accessed on September 22, 2016).
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-45.
- Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603-18.
- Chronic Care Management Services. Department of Health and Human Services Centers for Medicare and Medicaid Services 2015;ICN 909188 May.
- Chronic Care Management Tool Kit. American College of Physicians. 2015. https://www.acponline.org/system/files/documents/running_practice/payment_coding/medica re/chronic_care_manage ment_toolkit.pdf (Accessed on September 22, 2016).
- Edwards ST, Landon BE. Medicare's chronic care management payment--payment reform for primary care. N Engl J Med 2014;371:2049-51.
- Thompson CA. CMS explains Medicare payment for chronic care management services. Am J Health Syst Pharm 2015;72:514-5.
- Medicare Program Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). 2016. http://federalregister.gov/a/2016-16097 (Accessed December 9, 2016).