CCM as a Glidepath into Value-based Care

By Justin Barnes
LinkedIn: Justin Barnes, FHIMSS
X: @HITAdvisor

Last month, the CDC reported that 90 percent of our annual $4.5 trillion in healthcare spending is devoted to people with chronic and mental health conditions. And we know that 70 percent of Medicare beneficiaries, for example, suffer from two or more chronic conditions. These are staggering numbers we can’t turn away from, and a daunting challenge for physicians trying to improve outcomes and build a sustainable practice. Same for group practices and IDNs all the way to large hospital systems. We’ve also seen the studies showing that patient costs without coordinated care are 75 percent higher than when care coordination is implemented.

In my last article, it was detailed how CMS has finally allowed concurrent reimbursement (same patient/same month) for patients in chronic care management and remote physiologic or remote therapeutic management, billing for the care management (read care coordination) codes. For CCM this means complex and non-complex, behavioral health integration (speaking of mental health), principal care management, transition and the new chronic pain management codes.

How to build Chronic Care Management into Value-based Care

Knowing all of this, one key to improving care, cutting costs, and increasing revenue is through available value-based care levers providing a foundation toward more favorable payer negotiation. Along the way you can take advantage of regulatory business models toward scaling the number of patients.

The great majority of the CCM codes – and all of the RPM and RTM codes (minus just RPM 99091), allow them to be conducted under general supervision, also known as incident to, by clinical staff. This basically means that a physician can contract with a third party to conduct the codes under a financial contract. This lends to scale.

Does it sound too expensive to sacrifice a portion of reimbursement dollars? A published study from 2023 by a large academic medical facility found revenue increases of $332 per patient per year when CCM was conducted by a registered nurse, and likewise $372 when delivered by medical assistants. At the independent physician and medical practice level, it’s very common to see care providers generate an additional $12,000.00 per month in care management revenue. That is a significant return-on-investment (ROI) for any size healthcare organization.

Start with MIPS and ACOs

Now knowing all of this, let’s take a look at a VBC starting point such as MIPS quality reporting. All non-exempt Medicare docs are subject to reporting into the Merit-based Incentive Payment System.

Did you know that conducting CCM can qualify for up to 33 of the MIPS quality measures, 22 of those being high priority? Where’s the value? According to the AMA, 2023 average MIPS bonuses are projected at 3.71 percent. Chronic disease management, patient engagement and care coordination are the types of MIPS measures that fit.

On the other side, a projected 308,000 can face a penalty, which can run from negative 3 to nine percent. Couple that with annual cuts to the Physician Fee Schedule and that’s a sizable potential drop, or gain, when it comes to MIPS positive bonus funds.

For ACOs, which are built on care coordination, VBC contracts can allow them to share data analytics across providers through a hub system to multiple practices in the ACO, streamlining CCM capabilities.

Starting points and specialty specific

Researching and understanding how to bill for CCM and RPM, for example, along with exploring general supervision and scale, is a starting point. There are many credible vendors in the industry that can help you there as well. A best practice is to ask the vendor for a recent case study in your specialty that affords you a glimpse into how you would be successful with their platform. A case study or white paper that makes you feel comfortable.

If MIPS reporting is required, or if you’re part of an ACO, there are also ways to improve operations and revenue, and of course patient satisfaction and outcomes.

From there, the ability to propose VBC models with payers, and particularly to explore or propose models matching a specialty, can lead to more sophisticated and upside VBC strength long term. For all of us as stakeholders in healthcare, it’s a journey that must begin.

A roadmap to come…

Our next piece in this series will start to highlight chronic care management best practices by specialty so stay tuned!

This article was originally published on Justin Barnes’ blog and is republished here with permission.