Copay Concerns: The CCM Conundrum

susanlaneseyBy Susan Lanesey, RN, MBA, Founder, President & CEO, Stone Health Innovations
Twitter: @slanesey

I have the pleasure of speaking with physicians almost every day, particularly primary care physicians in independent practice. Without a doubt, I learn something valuable every time I meet with them from clinical matters to business matters. Almost all of them are looking for solutions. They look for solutions to improve the health of their patients as a priority. But they are also looking for solutions (always) to reduce the burden of cost of care on their patients and for solutions that will help them to “like being a doctor again”. They want to remain independent. They become disheartened speaking about the fact that they watch more and more of themselves each day being gobbled up by large institutions. They are tired of battling against rising costs and lower reimbursements and the frustrations of unending administrative burden.

Some of the most interesting conversations I have with primary care physicians surrounds the idea of the new CMS Chronic Care Management program (CPT 99490). Primary Care Physicians share with me, a luke- warm response to this new reimbursement from CMS, although for years they or their associations have lobbied and asked CMS to provide reimbursement for the work and time they put into caring for their many Medicare patients that have chronic conditions. Initially, I found their lack of passion for the program very curious and confusing.

But now, I think I understand.

Primary Care Physicians are a caring type. They care about the health of their patients. They care about the financial impact of the services they provide to their patients. They care about the relationships they have with their patients and they will fight to the end to protect that relationship. These are a caring type of provider and because they care enough to call their patients by their first name and remember to ask how their vacation to Florida was last week, or how that new grand baby is, they sometimes forget to care about themselves and neglect the holistic view of their practice.

The new chronic care management reimbursement is one of those “things” they forget about or unfortunately “don’t have the time to think through fully”. They forget about how important it is as a tool for their practice to increase patient engagement and practice revenue to help them to remain independent and to get paid for the value they truly provide to their Medicare patients.

More importantly perhaps, though, is that they don’t allow themselves the time to recognize the value it holds for their patients because what they see is the negative of the copay, not the value of the program. Although there are many out there, an incredible study that is worth the read for all primary care physicians who are the caring type and don’t want to burden their patients with additional copays associated with the new CMS CCM program is out on NCBI. Hamer, B. et al: The Impact of a Proactive Chronic Care Management Program on Hospital Admission Rates in a German Health Insurance Society. The study, an oldie but a goodie, shows the very positive impact of a “proactive” chronic care management program in regard to the significant reduction in inpatient visits realized particularly in the high and rising risk chronic population. In addition to this very positive outcome, the study notes that the more outreach engagement to the patients, the better the outcome in reduction in higher cost inpatient utilization.

Many primary care physicians express a sincere concern with the associated copay that their Medicare patients would be exposed to in implementing a CCM program in their practices. Yes, the chronic care management code CPT 99490 comes with a 20% copay to Medicare patients which equals a total of $95 a year (if enrolled and engaged monthly for a full year). CMS does not have the liberty to change that copay obligation to the patient. Although, it does propose raising the CCM PMPM reimbursement rate and extending reimbursement beyond 20 minutes for those patients who need more management time starting in 2017. However, in comparing the copay that a patient is exposed to that easily would amount to over $1500 for just one inpatient visit with a 4 day LOS, or the $250 copay the patient would feel for just one ER visit versus the annual copay of $95 for the CCM program, which provides significant value to their patients in reduction in higher cost utilization, better engagement and better health, primary care physicians should feel very comfortable in recommending the CCM program to their patients and in implementing a CCM program in their practices which at the same time would allow them the help they deserve in doing what they do even better.

I think Primary Care Physicians deserve to care for themselves as well as they care for their patients. They owe it to themselves to take a second look at the value of the CCM program to their own wellbeing, reduction in their administrative burden and to the sustainability of their independent practices that so many are struggling to maintain. After all, Healthier Practices lead to Healthier Patients.

And like my Primary Care Physician colleagues, I care about that.