How to Use HIT for CCM

PHYTEL | WHITEPAPER
How to Use HIT in Medicare’s
Chronic Care Management Program

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com2 Copyright ©2015 Phytel Inc. All rights reserved.
Introduction
Background
CCM Program: The Basics

EHR Limitations
CCM Infrastructure Components

Conclusion
Notes
Contents
Page 3
Page 5
Page 7
Page 10
Page 11
Page 14
Page 15

PHYTEL 11511 Luna Road, Suite 600 | Dallas, TX 75234 | 800.559.3057 | phytel.com Copyright ©2015 Phytel Inc. All rights reserved. 3
Introduction
Facing a sharp increase in future costs because of demographic trends,1
the Centers for Medicare and Medicaid
Services (CMS) is trying to reduce spending on its chronically ill Medicare beneficiaries, who generate most of
that program’s expenditures.2
In 2010, more than two-thirds of Medicare patients had multiple chronic conditions, and they accounted for
93% of Medicare spending. Beneficiaries with multiple chronic diseases accounted for almost all Medicare
hospital readmissions. And those with six or more chronic conditions generated about half of Medicare costs.3
“Multiple chronic conditions increase the risks for poor outcomes such as mortality and functional limitations as
well as the risk of high cost services such as hospitalizations and emergency room visits,” states a CMS report on
this issue.4
Primary care physicians deliver the bulk of chronic care. But with the population growing and aging faster than
new generalists are being added to the physician workforce,5
doctors are often finding they do not have the
time to deliver all the recommended chronic care to patients during office visits. In fact, it has been estimated
that to do so would require 10.6 hours a day.6
Moreover, physicians in the fee-for-service Medicare program are
being paid mostly for face-to-face office visits, not for the non-visit care that is required to care adequately for
people with multiple chronic diseases.
In 2013, CMS took a big step toward reimbursing physicians for non-visit care by launching the Transitional
Care Management Program.7
With the introduction of its Chronic Care Management (CCM) program on
Jan. 1, 2015, the agency has gone much further in paying for chronic care outside of office visits. The CCM
program rewards primary care practices for providing continuous care to the sickest Medicare fee-for-service
beneficiaries.8
In essence, the CCM program pays physicians and midlevel practitioners an average of about $42 per patient
per month for managing the care of Medicare beneficiaries with two or more chronic conditions. For each
eligible patient, practices must perform non-face-to-face care management and care coordination activities for
20 minutes per month and must meet an array of other requirements.9
WiththeintroductionofitsChronic
CareManagement(CCM)program
onJan.1,2015,CMShasgone
muchfurtherinpayingforchronic
careoutsideofofficevisits.The
CCMprogramrewardsprimarycare
practicesforprovidingcontinuous
caretothesickestMedicarefee-for-
servicebeneficiaries.

The potential financial gains are substantial. If
a physician has 150 eligible Medicare patients,
he or she stands to earn more each year from
CCM than from the entire Meaningful Use
EHR incentive program.10
Nevertheless, observers agree that the CCM
regulations will be challenging for the average
practice, partly because the majority of groups
lack the infrastructure they need for CCM.
In fact, Ron Ritchey, the chief medical officer
at eQHealth Solutions, the Medicare quality
improvement organization in Louisiana, told
Healthcare Informatics that physicians should
not view CCM payments as a windfall. Instead,
he said, they should use the money to invest in
the infrastructure needed for patient-centered
medical homes (PCMHs) and to gear up for
value-based reimbursement.11
Health IT is a key part of the infrastructure
that is necessary for both PCMHs and CCM.
For starters, the CCM regulations require
participating physicians to have certified EHRs
that meet the 2011 or the 2014 criteria.12
With
the help of those EHRs, practices are expected
to perform a wide range of functions related to
care management and care coordination.
There is a lot of overlap between CCM
functions and the features of the patient-
centered medical home. Indeed, CMS has
stated that the CCM program is, in part,
a response to the need of PCMHs for
reimbursement of their care coordination
activities outside of office visits.13
So if a
practice meets all of the requirements for
Level 3 PCMH recognition by the National
Committee on Quality Assurance (NCQA),
some observers believe, it should have no
problem in delivering the type of chronic
disease care that CMS mandates.14
But even PCMHs should bear in mind that they
will still be facing these significant challenges:
• Involving patients with the comprehensive
care plans that CMS requires.
• Engaging hospitals and specialists, who are
not currently being paid extra for chronic
care management, to coordinate with
primary care physicians.
• Adapting EHRs that are often not
configured for chronic care management or
non-visit care.
• Automating the routine processes of
chronic care so that the needs of these
sick Medicare patients won’t overwhelm
the practice.
This paper explains what CMS expects
providers to do in exchange for the CCM fees.
In addition, it describes some best practices
for using health IT to support the effort and
maximize the chances of success.
Thepotential
financialgainsare
substantial.Ifa
physicianhas
150eligibleMedicare
patients,heorshe
standstoearnmore
eachyearfromCCM
thanfromtheentire
MeaningfulUseEHR
incentiveprogram.

Background
Chronic diseases generate more than three-quarters of U.S. health spending, and an even higher percentage
of Medicare costs. Because the prevalence of these conditions rises with age, chronic diseases have a greater
impact on Medicare beneficiaries than on the population as a whole.14
In 2010, 21.4 million Medicare beneficiaries, more than two-thirds of the total, had multiple
chronic conditions. The most common conditions were hypertension (58%), high cholesterol
(45%), heart disease (31%), arthritis (29%), and diabetes (28%). Other chronic illnesses widespread
among Medicare patients included heart failure, chronic kidney disease, depression, COPD,
Alzheimer’s disease, atrial fibrillation, cancer, osteoporosis, asthma, and stroke.15
Thirty-two percent of Medicare beneficiaries had two or three chronic conditions, 23% had four
or five, and 14% had six or more. Among those with four or more diseases, there was a strong
correlation between age and the number of conditions.
More than 60% of patients with six or more conditions were hospitalized in 2010, and those
patients accounted for 63% of post-acute care costs. Ninety-two percent of those patients had a
doctor visit, and 46% had 13 or more visits. Seventy percent of them had an ER visit, and over a
quarter had three or more visits.
On average, CMS spent $9,738 per Medicare beneficiary in 2012. The cost rose steeply with
the number of chronic conditions, reaching an average of $32,658 for patients with six or more
conditions.16
OLDER ADULTS ARE MORE LIKELY TO HAVE MULTIPLE CHRONIC CONDITIONS
PERCENTAGE OF POPULATION WITH CHRONIC CONDITIONS
6.7%
27%
16.8%
40.3%
42.8%
68%
73.1%
90.7%
A G E S 0 - 1 9
O N E O R M O R E C H R O N I C C O N D I T I O N S
T W O O R M O R E C H R O N I C C O N D I T I O N S
A G E S 2 0 - 4 4 A G E S 4 5 - 6 4 A G E S 6 5 +
0
2 0
4 0
6 0
8 0
1 0 0
Source: Robert Wood Johnson Foundation, www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583

Inadequate care
Patients with multiple chronic conditions use
medical goods and services at higher rates
than other patients do, and they often receive
duplicate tests, drug prescriptions that are
contraindicated, and/or conflicting treatment
advice.17
This is not surprising in light of the
fragmentation of chronic care. More than half
of patients with serious chronic conditions
have three or more physicians.18
The average
number of physicians that a chronically ill
Medicare patient sees ranges from four for
those who have just one condition to 14 for
those with five or more conditions.19
One study
explains the situation as follows:
System fragmentation means that
chronically ill patients receive
episodic care from multiple providers
who rarely coordinate the care they
deliver. Because of this structural
deficiency, patients with chronic
illnesses receive only 56 percent
of clinically recommended medical
care. That gap in care may explain a
nontrivial portion of morbidity and
excess mortality.20
When patients with multiple chronic
conditions do not receive recommended
ambulatory care in a coordinated fashion,
they are hospitalized more often than
they otherwise would be.21
One study of
“ambulatory-care sensitive conditions” found
that hospitalizations of patients with these
chronic diseases rise steeply with the number
of conditions: For Medicare beneficiaries
with two conditions, there are nine avoidable
hospital admissions per 1,000 Medicare
beneficiaries; for those with six conditions, the
number is 109.22
Considering all of these facts, it is clear that
patients with multiple chronic illnesses
could benefit—and that the cost of their care
would drop—if they received appropriate,
coordinated care. The purpose of the CCM
program is to encourage primary care
physicians to provide this kind of care to
Medicare beneficiaries.
Itisclearthat
patientswith
multiplechronic
illnessescould
benefit—andthat
thecostoftheir
carewoulddrop—
iftheyreceived
appropriate,
coordinatedcare.
Thepurposeofthe
CCMprogramisto
encourageprimary
carephysiciansto
providethiskindof
caretoMedicare
beneficiaries.

CCM Program: The Basics
Under the CCM program, eligible providers are paid an average of $41.92 per month for each eligible patient
for whom they provide the requisite services.23
Of that amount, CMS pays 80% and the patient pays 20%, or
$8.40, as a copayment.
To be eligible for CCM, a patient must be in the Medicare fee-for-service program and have two or more chronic
conditions. These conditions must be expected to last for at least 12 months or until the patient dies. They must
threaten the patient with the risk of death, acute exacerbation/decompensation, or functional decline.
Physicians and other eligible providers must ask each eligible patient for permission to be their CCM provider.
The clinicians must explain what CCM is and receive the patient’s written consent, including authorization for
data sharing with other treating providers. The patient must also be informed that only one provider can bill for
the CCM services provided to that person in any month.
Primary care physicians, nurse practitioners, and physician assistants can bill for CCM. Specialists who provide
the bulk of a patient’s care can also do so, but must meet all of the same requirements as primary care providers.
Any certified healthcare professional, including a certified medical assistant, can provide CCM services.
Contracted clinicians, such as covering or locum tenens physicians, can also deliver CCM services as long as
they have access to the patient’s electronic record and are under the general supervision of the CCM physician
or another designated practitioner.
For this program, CMS has relaxed the rules regarding direct physician supervision of non-physician clinicians.
A doctor need not be in the same location as another clinician who is providing CCM services.24-25
Scope of services
CCM services fall roughly into two buckets: non-face-to-face care management and care coordination
activities that involve communications with other providers and community agencies. These services have been
summarized as follows:
• 24/7 access to care management services
• Continuity of care with a designated practitioner or member of a care team
• Care management, including an assessment of the patient’s medical, functional, and psychosocial needs;
preventive care; medication reconciliation; and oversight of the patient’s medication self-management
• Creation of a patient-centered care plan that fits patients’ choices
and values
• Management of care transitions, including referrals, follow-up after
an ER visit, and follow-up after discharge from a hospital, skilled
nursing facility, or other healthcare facility
• Coordination with home- and community-based clinical service
providers to meet patients’ psychosocial needs and address their
functional deficits
• Enhanced opportunities for a patient and any relevant caregiver to
communicate with the provider regarding the beneficiary’s care
• Electronic capture and sharing of care plan information.26
TobeeligibleforCCM,apatientmust
beintheMedicarefee-for-service
programandhavetwoormore
chronicconditions.Theseconditions
mustbeexpectedtolastforatleast
12monthsoruntilthepatientdies.
Theymustthreatenthepatientwith
theriskofdeath,acuteexacerbation/
decompensation,orfunctionaldecline.

The designated CCM clinician must establish,
implement, revise, or monitor and manage an
electronic care plan based on an assessment of
the physical, mental, cognitive, psychosocial,
functional and environmental needs of the
patient. The care plan must contain a record
of all recommended preventive care services,
medication reconciliation with review of
adherence and potential interactions, and
oversight of patient self-management of
medications. It must also include an inventory
of clinicians, resources, and supports specific
to each patient, including a description of
how the services of agencies or specialists
unconnected to the designated clinician’s
practice will be coordinated.
This care plan must be available to all members
of the practice care team at all times. In
addition, it must be shared with providers
in other practice settings who are caring
for the same patient. As we explain later,
this requirement will pose a technological
challenge to many providers.27
Time-related requirements
To bill for CCM in any given month, the care
team of an eligible provider must provide
at least 20 minutes per month of non-face-
to-face care management and/or care
coordination to a patient who has agreed to
receive CCM services. Care team members
may perform such activities in one block of
time or in bits and pieces during the month.
They must keep track of the time they spend
on that patient and document it in the record.28
Among the activities that count toward the
20-minute total are:
• Phone calls and emails with the patient
• Time spent coordinating care (by phone
or other electronic communication, but not
fax) with other clinicians, facilities,
community resources, and caregivers
• Time spent on prescription management
and medication reconciliation.29
Remote patient monitoring, using devices
that communicate online with the practice,
does not count toward the 20 minutes of
CCM services. Providers can include the time
they spend reviewing physiologic data from
monitoring devices, according to the American
Telemedicine Association (ATA). But they
cannot bill CMS’ code for that service if they’re
doing it as part of their CCM activities.30
Billing rules
CMS also rules out potential billing in
duplicative areas. If a provider bills the CCM
code (99490) for a particular patient, that
provider cannot, in the same month and for
the same patient, bill for transitional care
management, home health supervision,
hospice care supervision, or certain end-stage-
renal-disease (ESRD) services. The provider
can, however, bill those codes for non-CCM
patients to whom he or she provides those
services. Office visits by CCM patients can
also be billed separately in the same month
in which CCM services are delivered to those
patients.31
CHRONIC CARE
MANAGEMENT PROGRAM
AMONG THE ACTIVITIES THAT
COUNT TOWARD THE 20-MINUTE
TOTAL ARE:
Phone calls and emails
with the patient.
Time spent coordinating
care (by phone or other
electronic communication,
but not fax) with other
clinicians, facilities,
community resources, and
caregivers.
Time spent on prescription
management and medication
reconciliation.29
TobillforCCMin
anygivenmonth,
thecareteamof
aneligibleprovider
mustprovideat
least20minutes
permonthofnon-
face-to-facecare
managementand/
orcarecoordination
toapatientwhohas
agreedtoreceive
CCMservices.

Practices must make sure they have provided
20 minutes of CCM services to each patient
within the month for which they’re billing. It
is possible that they might not perform these
services for 20 minutes for certain patients
every month; if so, practices cannot bill for
those patients in those months.32
Economic calculation
The economics of CCM are compelling for
practices that have a certified EHR and have
implemented the necessary workflow changes.
Margalit Gur-Arie, a principal of the BizMed
consulting firm, has provided one of the best
explanations of how much physicians can
expect to earn from CCM.33
Based on a payment of $40 per patient per
month, she estimates, a single CCM patient
can generate $380-$480 per year, depending
on whether a practice can collect the $8
copayment.
The average primary care physician has
roughly 200 Medicare fee for service patients
with multiple chronic conditions, she says.
Of those patients, about 150 will probably
consent to receiving CCM services. At the
rates specified above, those patients will bring
in $60,000-$72,000 a year in CCM revenue for
each primary care physician.
For those 150 patients, a practice will have to
provide at least 50 hours per month of CCM
services at 20 minutes per patient. Fifty hours
a month is about a third of the time a full-time
equivalent employee spends at work in a
typical practice. So if the average non-physician
clinician on the care team were paid $30,000
a year, the labor expense for CCM would be
$10,000 per year, or $67 per patient per year.
Adding in the “setup cost” and other expenses,
which Gur-Arie estimates at $5,000, the total
cost of providing CCM services would be about
$15,000, or $100 per patient per year. That
leaves net revenue of $45,000-$57,000 per
provider.
Care must be taken, however, in applying these
calculations. First, they don’t include the cost of
building infrastructure, which can, however, be
paid off over time. Second, some physician time
will be required to supervise CCM activities
and communicate with patients. Third, some
non-provider care team members may earn
more than $30,000 a year, which would raise
the labor cost. And finally, there’s no guarantee
that the care management and coordination
that any patient needs will be limited to 20
minutes per month. That is why practices must
look beyond CMS’ bare bones requirements
and figure out how to make their chronic care
management as efficient as possible.
ASSUMPTIONSFORONEPHYSICIAN:
On average, one physician is
responsible for roughly 200
Medicare FFS patients with
multiple chronic conditions.
Of those, 150 will most
likely consent to participate
in the CCM program.
Each of these participating
patients will be billed
$40/month.
The annual revenue for
this group of patients
totals $72,000. of potential revenue for
CCM services.
100physiciansthat’s
Andifagrouphad
7,200,000$

EHR Limitations
As mentioned earlier, a provider who wishes to bill for CCM must have a 2011 edition or a 2014 edition
certified EHR. At a minimum, that EHR must be used for:
• Structured documentation of demographics, problems, medications, and allergies
• Creation and transmittal of electronic care summaries to other providers
• Storage of Medicare beneficiary consent forms
• Documentation that the care plan was given to the beneficiary
• Recording of care coordination activities, including communications with other providers and
community agencies.
In addition, practices must use an EHR or some other kind of application to document their list of
CCM patients, the CCM protocols for the care team, and the CCM services that were provided,
including what they were, who provided them, when they were provided, and how long they took.34
Devising a longitudinal and comprehensive care plan often exceeds the capabilities of current
EHRs. Most EHRs confine their care plan documentation to the assessment and plan section of
the visit note. They also lack templates for performing wide-ranging patient health assessments.
There is no requirement, however, that the care plan must be created in the EHR. After it is built, it
can be stored in the EHR as a document.
Similarly, EHRs can lack the robust registry, analytics, and automation functions required for
chronic care management. Reports on patients with particular conditions are difficult to program
in some EHRs and are rigidly prebuilt in others. Moreover, except for canned health maintenance
alerts, the information in these reports is not available at the point of care.
EHRs also are not designed to support the work of care teams. A recent study found that EHRs
lack integrated care manager software and are inadequate for tracking patient data over time.35
EHRs may not have good methods of documenting non-visit care or care coordination activities.
Phone calls and emails, whether between providers or between providers and patients, can
be documented. Some EHRs also allow clinicians to capture non-billable encounters and add
some notes. But the systems are not designed to allow care team members who provided CCM
services to document most of them, because doctors must enter this information for ordinary
fee-for-service billing. Moreover, EHRs don’t provide any way to record the duration of non-visit
encounters or care coordination activities.
It’s possible to create Excel spreadsheets outside your EHR for some of these functions. But
those spreadsheets cannot identify care gaps, cannot be used to trigger patient outreach, and
have limited actionable utility to care managers. In addition, the patient data in the EHR must be
transferred manually to these spreadsheets.
For practices that find spreadsheets inadequate, specialized software that interfaces with
EHRs and performs most of the CCM functions is available. If they have already implemented
the process changes required for PCMH recognition, they might be able to make do with EHR
workarounds. Many PCMHs also use ancillary population health management software with their
EHRs, and NCQA awards auto-credits for the use of some solutions.
Practicesmust
useanEHRor
someotherkind
ofapplicationto
documenttheirlist
ofCCMpatients,
theCCMprotocols
forthecareteam,
andtheCCM
servicesthatwere
provided,including
whattheywere,
whoprovidedthem,
whentheywere
provided,andhow
longtheytook

CCM Infrastructure Components
The first step in establishing a process for CCM is to search the practice’s EHR for Medicare patients who
have two or more chronic conditions and meet the other criteria. This is easier to do with a standalone patient-
centric chronic disease registry, which makes such reports easier to generate. Then the practice must create a
log of CCM-eligible patients and must attribute each to a particular physician or other provider.
Next, the practice has to contact these patients so that their physician can discuss the CCM program with
them, invite them to participate, and ask them to sign permission forms. If they haven’t had a Medicare-covered
well visit in more than a year, they might be asked to come in for that and at the same time discuss the CCM
program. Alternatively, they might be approached during their next scheduled follow-up visit or reminded to
make an appointment if they’re overdue for recommended care.
The outbound messaging to patients about the need to make appointments can be done automatically with
software attached to a patient-centered registry. Otherwise, nurses must call the patients individually or send
them letters.
Care Plans
Physicians and clinicians can work with patients to build care plans during visits, but practices should consider
asking patients to complete online questionnaires prior to those encounters. For example, practices can
use health risk assessments and functional status surveys to collect data on the physical, mental, cognitive,
psychosocial, functional and environmental needs of the patient.
Such an approach would save a lot of time for a clinician in a busy primary care practice who is trying to assess
the health of 150 patients. It would also be likely to supply more consistent and comprehensive data than
interviews alone could elicit.
Once this information has been collected, practices can modify EHR templates or use homegrown forms or
software outside their EHR to construct care plans. Ideally, such care plans should be usable by care managers.
They should include fields for documenting progress toward patient goals, interventions, and the amount of
time spent on CCM services.

Practicesthattackle
CCMshouldconsider
acquiringpopulation
healthmanagement
softwaretoautomate
theirchroniccare
management
processes.Such
applicationscan
enablethemto
quicklyscaleupto
handle,forexample,
150highrisk
Medicarepatients
perprovider,andthey
canusethesame
softwaretofacilitate
caremanagementfor
otherpatientswith
chronicconditions.
Information Sharing
Every patient enrolled in CCM must have
access to a copy of his or her care plan. This
can be provided through a patient portal
attached to the EHR. The same portal can be
used to enhance communications between
patients and care teams, including automated
reminders about preventive and chronic care.
Care team members must have online access
to the care plan 24/7. That is not a huge
challenge if they are all using the same EHR.
But, depending on how the system has set up
its security protocols, it might be more or less
difficult for a clinician to log into the system
from home or some other location.
A more complex challenge is posed by the
requirement that outside providers who care
for the patient have access to the care plan.
The CCM provider can use Direct messaging
or some other secure messaging system to
convey the plan to those providers, probably
as part of a referral; but it will have to be in
the form of a text document or PDF, which
not all EHRs accept as attachments to Direct
messages.
Moreover, the CCM provider must be aware
of who else is caring for the patient and must
know their Direct address. And the designated
provider must ensure that outside clinicians
see the plan whenever it is updated.
Care summaries must also be exchanged with
other providers to support care coordination.
Certified EHRs can generate a structured care
summary document called a CCDA, but the
lack of interoperability between EHRs and the
slow development of Direct messaging still
impede the exchange of CCDAs.
Most EHRs include referral modules, and
Direct messaging is often part of those
modules in the latest upgrades. But most
EHRs don’t track whether patients made
appointments with the specialists or whether
those consultants sent reports back to the
referring physicians. So practices must set up
a workflow to monitor referrals to and reports
from specialists. High performing PCMH
practices will already have these processes in
place, and CCM is poised to leverage them.
Transitional care management
Follow-up with patients after they have been
discharged from a hospital or an ER is a key
component of CCM. The biggest challenge
here is not technological; it’s getting hospitals
to send discharge summaries on a timely basis
and to inform physicians when their patients
have been admitted or have visited the ER.
A recent study shows that this is still a major
problem for many doctors.36
Hospitals can facilitate transitions of care
by using the same EHRs that primary care
doctors do, and this is one reason why so many
healthcare organizations favor integrated
systems. But even if these organizations have
their employed physicians on the same EHR
as the hospital, they still may not be able to
communicate online with community doctors.
The challenge is even greater where post-
acute-care providers are concerned. Nursing
homes and home health agencies have partially
computerized, but most of the systems they
use are not interfaced with inpatient or
ambulatory EHRs. So these communications
will continue to rely on phone and fax.
Despite these barriers, CCM providers must
try to obtain as much of this transition of care
information as they can. If they know when a
patient has been admitted and do not round in
the hospital, they should have some method of
flagging the patient’s admission in their EHR
and finding out when they’ve been discharged.
They also need to reach out to patients to
find out whether they understand their
discharge instructions and to remind them to
make appointments to see their primary care
doctors. Software is available to automate both
of the latter functions.

Automation of care management
Care management is a very labor-intensive
function, even if it is limited to patients with
multiple chronic conditions. In the financial
scenario cited earlier, only a third of an FTE
clinician’s time was required to meet the CCM
requirements of 20 minutes per patient per
month. Spread over several people, that might
seem like a fairly small time investment. But
if a CCM patient has an exacerbation or one
of their conditions is out of control, those 20
minutes could easily balloon into hours.
Moreover, physicians find it difficult to
compartmentalize a treatment approach by
limiting it to patients with a particular type of
insurance. Once they change their mindset and
their office workflow to accommodate CCM,
they’re likely to extend the same approach to
other patients with chronic conditions.
For this reason practices that tackle CCM
should consider acquiring population health
management software to automate their
chronic care management processes. Such
applications can enable them to quickly scale
up to handle 150 high risk Medicare patients
per provider, and they can use the same
software to facilitate care management for
other patients with chronic conditions.
This kind of automation can help practices
identify and manage high-risk patients and
can enable care managers to handle far more
patients than they can with manual processes.
As a result, the practices can meet CCM
requirements with fewer FTEs while ensuring
that patients who need care don’t fall through
the cracks.
Routine functions
Automation can’t be used to build care
plans, and it can’t substitute for one-to-one
interactions between care team members and
patients. But automation and analytic software
can perform many routine functions that
would otherwise take up enormous amounts
of staff time.
Practices can use this kind of software to
identify high-risk patients, detect their care
gaps, and suggest specific interventions to
care managers. This type of program must be
supplied with a wide range of clinical protocols
to cover all of the possible situations that care
managers might encounter.
Within a CCM population are patients who
need very different kinds of care, some
more urgently than others. The needs of a
patient with cancer or Alzheimer’s disease,
for example, are very different than those of
people who have diabetes or hypertension.
And the comorbidities that patients with
multiple chronic diseases have are also very
different, requiring different treatment and
self-care strategies.
To support care management, registry-
linked applications can send patients online
educational materials tailored to each patient’s
unique set of conditions. Care managers can
use analytic software to decide which of their
patients need the most help and coach them
intensively to improve their understanding
of their conditions and how to manage them.
Self-management of medications—one of the
specific requirements of CCM—can especially
benefit from this approach.
Automated campaigns can also be created to
help patients who have specific comorbidities
manage their own conditions better. Although
the time spent programming these online
interventions can’t be counted as part of
the required 20 minutes of CCM activities,
they can prepare CCM patients for their
interactions with care managers and providers.
Automationcanhelppracticesidentifyandmanagehigh-riskpatientsandcan
enablecaremanagerstohandlefarmorepatientsthantheycanwithmanual
processes.Asaresult,thepracticescanmeetCCMrequirementswithfewerFTEs
whileensuringthatpatientswhoneedcaredon’tfallthroughthecracks.

Conclusion
Medicare’s CCM program is a great opportunity for primary care practices that are already providing extensive
care coordination as patient-centered medical homes. While some commercial payers have been giving care
coordination fees or other incentives to PCMHs, CCM offers the most substantial and sustainable reward to
PCMHs and other primary care providers for what many of them have been doing for free or with term-limited
grant subsidies up to now.
The financial incentive in the CCM program is substantial, but it requires an investment in infrastructure and a
commitment to change that many practices will find daunting. If a group hasn’t formed a PCMH, it will have to build
care teams and train them to focus on chronic care, both during and between visits. A great deal of bridge building
with hospitals, specialists, and post-acute-care providers will be required. And the practice will have to change
its work processes to become more patient centered and to accommodate the requirements of the information
technology it is putting in place.
Obviously, large groups have more resources to meet these challenges than small ones do. But small and medium
sized groups can take advantage of CCM, too, especially if they’re willing to do the work to achieve NCQA
recognition as a medical home. In either case, practices would be well advised to consider using ancillary software
designed for population health management.
The potential benefits of CCM go far beyond the direct payments from Medicare. Engaging in this program could
prepare practices to participate in alternative payment models and value-based reimbursement. They could apply
the same health IT and workflows they use for CCM to all of their chronically ill patients. And in the end, seizing
this opportunity can pay off in spades for the patients who will get the care they need to become healthier, avoid
unnecessary services, and enjoy a better quality of life.
ThepotentialbenefitsofCCMgofar
beyondthedirectpaymentsfrom
Medicare.Engaginginthisprogram
couldpreparepracticestoparticipate
inalternativepaymentmodelsand
value-basedreimbursement.

1. David Blumenthal, Karen Davis, and Stuart Guterman, “Medicare at 50—Moving Forward,” NEJM,
Jan. 28, 2015 DOI: 10.1056/NEJMhpr1414856.
2. Mark Hagland, “Medicare’s New Chronic Care Management Codes for MDs: Clinical IT and Other
Requirements,” Healthcare Informatics, Jan. 14, 2015.
3. Centers for Medicare and Medicaid Services (CMS), “Chronic Conditions Among Medicare
Beneficiaries: 2012 Chartbook,” http://www.cms.gov/Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf.
4. Ibid.
5. Stephen M. Petterson, Winston R. Liaw, Robert L. Phillips, David L. Rabin, David S. Meyers, and
Andrew W. Bazemore, “Projecting US Primary Care Physician Workforce Needs: 2010-2025,” Annals
of Family Medicine 2012;10:503-509.
6. Thomas Bodenheimer, “Coordinating Care—a Perilous Journey Through the Health Care System,”
NEJM 358, no. 10 (2008); 1064-1071.
7. CMS, “Transitional Care Management Services,” http://cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-
Sheet-ICN908628.pdf
8. CMS Fact Sheet: “Proposed policy and payment changes to the Medicare Physician Fee Schedule
for Calendar Year 2015,” July 3, 2014, http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-
sheets/2014-Fact-sheets-items/2014-07-03-1.html
9. Ibid.
10. BizMed webinar, “Chronic Care Management,” https://www.bizmedtoolbox.com/Documentation/
Library/5/2015013011333871820150130113338718Default.pdf
11. Hagland, “Medicare’s New Chronic Care Management Codes.”
12. CMS, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical
Laboratory Fee Schedule & Other Revisions to Part B for CY 2014,” Federal Register, Dec. 10, 2013,
https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-
payment-policies-under-the-physician-fee-schedule-clinical-laboratory#h-310
13. CMS, “Revisions to Payment Policies Under the Medicare Physician Fee Schedule.”
14. BizMed webinar
15. Robert Wood Johnson Foundation and Johns Hopkins Bloomberg School of Public Health,
“Chronic Care: Making the Case for Ongoing Care,”2010, http://www.rwjf.org/content/dam/farm/
reports/reports/2010/rwjf54583
16. CMS, “Chronic Conditions Among Medicare Beneficiaries: 2012 Chartbook.”
17. RWJF and Bloomberg, “Chronic Care: Making the Case for Ongoing Care.”
18. Ibid.
19. Vogeli C, Shields AE, Lee TA, et. al. Multiple Chronic Conditions: Prevalence, Health Consequences,
and Implications for Quality, Care Management, and Costs. J Gen Intern Med. 2007 December;
22(Suppl 3): 391–395. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598/
Notes

20. Thorpe KE, Ogden LL, Galactionova K. Chronic Conditions Account For Rise In Medicare Spending
From 1987 to 2006. Health Aff April 2010 vol. 29 no. 4 718-724. http://content.healthaffairs.org/
content/29/4/718.full
21. RWJF and Bloomberg, “Chronic Care: Making the Case for Ongoing Care.”
22. Ibid.
23. CMS Fact Sheet
24. Kent Moore, “Chronic Care Management and Other New CPT Codes,” Family Practice Management.
2015 Jan-Feb;22(1):7-12.
25. AMGA , “Medicare Physician Fee Schedule Proposed Rule for Calendar Year 2015: Summary
of Key Provisions,” http://www.amga.org/wcm/Advocacy/Issues/RegAffs/2015FeeScheduleSummary.
pdf?WebsiteKey=366827a3-43b6-40f3-bd5c-703e097b3d0b&hkey=23abec7a-e4bb-40e6-8e64-
4760e2903395&=404%3bhttp%3a%2f%2fwww.amga.org%3a80%2fwcm%2fADV%2fCMS%2fwcm%
2fAdvocacy%2fIssues%2fRegAffs%2f2015FeeScheduleSummary.pdf
26. Moore and AMGA
27. American College of Physicians, “Chronic Care Management Tool Kit: What Practices Need to Do to
Implement and Bill CCM Codes,” https://www.acponline.org/running_practice/payment_coding/
medicare/chronic_care_management_toolkit.pdf
28. Ibid.
29. Ibid.
30. American Telemedicine Association, “Update on CMS Payment Decisions – Two Steps Forward, One
Back,” http://www.americantelemed.org/news-landing/2014/11/07/update-on-cms-payment-decisions-
--two-steps-forward-one-back#.VNEXGCmKJ4V
31. ACP, “Chronic Care Management Tool Kit.”
32. PYA white paper, “Providing and Billing Medicare for Chronic Care: Updated to Include 2015
Proposed Medicare Physician Fee Schedule,” 2014.
33. BizMed webinar
34. Ibid.
35. Ann S. O’Malley, Kevin Draper, Rebecca Gourevitch, Dori a. Cross, and Sarah Hudson Scholle,
“Electronic health records and support for primary care teamwork,” JAMIA. DOI: http://dx.doi.
org/10.1093/jamia/ocu029. First published online: 27 January 2015.
36. Chun-Ju Hsiao, Jennifer King, Esther Hing, and Alan E. Simon, “The Role of Health Information
Technology in Care Coordination in the United States,” Medical Care, February 2015, 53;2:184-90.

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