Transforming General Practitioners Into Value-Based Care Specialists With Chronic Care Management

Chronic Care Management is becoming somewhat of its own specialty — and that’s positively impacting patients and providers in the push toward value-based care.

By Travis Bond, CEO, CareSync

Providers greeted the arrival of the Centers for Medicare & Medicaid Services’ (CMS) CPT code 99490 for Chronic Care Management (CCM) with great enthusiasm. The prospect of reimbursement for using mobile health technology to connect with patients and reinforce care between visits and other providers represented a win-win for everyone.

Yet, as physicians dug into CCM, it became clear providers needed more guidance to interpret and maximize the value of the program. Patients, many of whom expected non-face-to-face healthcare services to be free, needed more tangible evidence of the program’s value to buy into it.

Nearly two years later, physicians now view CCM in a more realistic light — the beginning of value-based care as a distributed care model where patients and other providers are part of the evolution of healthcare. Within what is still the CCM adoption phase lies a ripe opportunity for primary care physicians to leverage the program and cultivate a new level of collaboration with patients and their caregivers for a more predictable and reliable framework for managing individuals with chronic disease.

By taking advantage of all CCM has to offer while the program is still relatively new, physicians are well positioned to emerge as leaders in their medical circles, and as specialists in administering the best value-based, technology-oriented, evidence-supported medicine available.

How CCM Helps Providers Extend Their Practice

CCM empowers physicians to oversee and coordinate care for Medicare patients with chronic conditions. By doing so, they drive meaningful change both clinically and financially. That’s exactly what CMS had in mind when it created the program as a key component of its movement toward value-based care.

CCM amplifies, or extends, the reach of the provider pursuing CCM services while allowing for the sharing of critical data and care plans among multiple providers, specialists, caregivers, and family members. It becomes a specialty that acts as a resource center on behalf of the provider and aggregator of data from all other providers on a broader scale.

To illustrate this point, let’s take the example of a cardiologist who is facilitating CCM services, acting as the “go-to” physician for a patient with chronic heart disease. Our cardiologist likely has a treatment plan he wants his patient to adhere to with the support of other secondary providers or caregivers of that patient. With a solid CCM program that reinforces his protocols, the cardiologist naturally emerges as the “specialist-in-chief,” a leader who oversees the patient’s care and wellbeing across the care continuum.

The act of coordinating information from multiple providers into one universal hub while giving patients the ongoing support they need, and encouraging engagement, also helps our cardiologist resolve one of the largest challenges associated with care: time — or rather, lack thereof.

Time is the biggest limiting factor all exams or hospital stays have working against them. It is the one element that is always required to transfer information, ask questions or give clarifying answers as new data arrive. Because of cost pressures and other financial factors, however, the amount of time a physician can spend with patients has significantly decreased in recent years and now hovers somewhere between 13 and 16 minutes per patient, according to the 2016 Medscape Physician Compensation Report.

While competing priorities put demands on physicians’ time with patients, CCM can help by empowering physicians to engage their patients in more meaningful care, through tools such as phone check-ins, remote monitoring or by answering email questions. CCM integrates into a medical practice’s workflow, so a physician can monitor everything from care plan compliance to medication adherence and even overall activities of daily living. All of these technology-based services translate into the patient feeling he or she is getting much-needed attention outside of the office. This typically results in patients who feel more engaged in their care and experience better outcomes, as shown by multiple studies published by the Agency for Healthcare Research and Quality.

CCM, MACRA And The Bigger Picture Of Value-Based Medicine

No discussion of CCM would be complete without touching on the ways in which CMS views the program as part of its larger intentions of creating a world where value-based care is ubiquitous. Therefore, physicians who embrace CCM and start to become experts, or specialists, in delivering CCM services, will have an easier time adhering to another critical piece in CMS’ bigger design: the Medicare Access and CHIP Reauthorization Act, or MACRA.

In an effort to combine CMS’ EHR Incentive program with other value-based initiatives, while repealing the Sustainable Growth Rate (SGR), CMS is offering, through MACRA, a path to transition to a care model that prioritizes outcomes and efficiency. As MACRA takes hold, physicians must figure out how to demonstrate value to patients. Those that do not, risk losing patients and taking a cut to their bottom line.

Programs that focus on meeting patients outside the point of care and managing them effectively increase the likelihood for providers and patients to truly stay in sync with each other. The outcome then becomes a good consumer experience that can be measured under MACRA.

CCM is the best chance for healthcare to achieve the delivery of time, attention and information that align with a good consumer experience. Physicians who implement CCM are in a unique position to rise above the noise around value-based care and set the bar as leaders for the next generation of healthcare.

About The Author

Travis Bond is CEO of CareSync. Follow him on Twitter @travislbond.