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10 Myths About Running a CCM Program

1. Targeting patients without copays for CCM enrollment is ok.

Truth: Denying services for Medicare patients based on whether they have a copay is not only unethical, it also violates multiple CMS policies. Providers should be careful in ensuring they offer equitable access to healthcare services for all Medicare patients.  

2. Providers are the best resource to enroll patients in a CCM program. 

Truth:  Have you ever seen a provider or physician discuss copay and deductibles with a patient?  Neither have we.  A compliance requirement of any CCM enrollment program is to ensure patients are being informed of their financial obligations related to copays and deductibles.  Trained Enrollment Specialists who can research patient demographic and insurance information are well-suited to educate and inform patients about a CCM program.  CMS requires that patients have an “initiating visit” by a provider or have been seen by that provider in the past 12 months, but the actual enrollment is best conducted by an Enrollment Specialist who can commit the time and resources required to achieve an informed patient consent.  Enrollment Specialists should document enrollments and it’s best to also record patient telephone audio enrollments for future Medicare audit purposes.  

3. CCM fee-for-service programs are not aligned with value-based care programs.

Truth: Claims data proves that this narrative is inaccurate. A two-year retrospective study of Medicare claims data, covering every patient in the U.S. enrolled in a CCM program, showed that for every dollar of gross savings achieved, 59 cents went to fee-for-service reimbursement and 41 cents achieved savings. CCM proves that volume can drive value by ensuring providers are paid upfront for their capital investment in the resources needed to run a CCM program and Medicare saves money for taxpayers after reimbursing providers for delivering CCM programs to their patients. 

4. CMS requires patients engage by phone, every month, in order for providers to be reimbursed.

Truth: CMS regulations do not require a monthly phone call with enrolled CCM patients.  While monthly engagement (phone or electronic) is strongly encouraged by Medicare, they realize not all patients will choose to engage every month. A policy of calling every patient, every month, is important.  Additionally, if patients only incur a copay if they engage, you are likely to turn your proactive, preventative CCM program into a reactive, sick care program, defeating the purpose of CCM. 

5. CCM call center analytics are not critical.

Truth: Without telephony analytics how will you evaluate and manage the performance of your clinical support team?  Operational metrics such as average time to answer, average time to respond to voice mail, and average length of call are important operational metrics to measure.  Without data transparency, you’ll be unable to identify problem areas and make improvements, impacting your ability to satisfactorily serve patients.  

6. Claims effectivity of CCM programs can’t be measured.

Truth: Medicare data is publicly available, and it shows CCM is one of the most effective value-based care programs CMS has ever launched based on reductions in in-patient, out-patient, and skilled nursing facility admissions.  

7. Quality/Pop Health teams are not aligned with CCM programs.

Truth: On average, Quality/Pop Health teams perform 10%-30% higher on quality measures when they leverage a CCM program to close care gaps.  Most health systems and practices will only touch their patients 3-4 times per year in a brick-and-mortar setting.  If a patient is enrolled in a CCM program, that patient will be touched 12-20 times by a CCM clinician, increasing the opportunities to close care gaps for that patient by 300%-400% a year.  

8. CCM enrollment is a one-time event.

Truth: Every day more than 11,000 patients churn into Medicare and more than 7,000 churn out.  Churn is inherent in any Medicare value-based program and your practice’s ability to manage the daily, weekly, and monthly patient churn associated with Medicare will be critical to maintaining the viability and volume of your CCM program. 

9. The CCM patient copay is going away.

Truth: CMS doesn’t have the legal ability to remove the patient copay.  The removal of the copay would need to be approved by Congress and the passing of such legislation is unlikely in the current political climate.  

10. Registered Nurses are best suited to provide CCM services.

Truth: The role of a CCM clinician is not to practice medicine…that is the job of the patient’s provider.  The role of a CCM clinician is to make sure the provider’s care instructions are being followed, medications are being refilled and taken, appointments are being adhered to and transportation barriers are overcome, and many other care coordination tasks.  Asking a nurse to perform these low-level tasks is beneath their licensure and a quick way to burn them out of their profession.  While nurses are important in the oversight and support of any clinical CCM cohort, they need to be properly used in the management of a CCM program, based on their skill sets and responsibilities.  

Sources:

https://www.mathematica.org/our-publications-and-findings/publications/evaluation-of-the-diffusion-and-impact-of-the-chronic-care-management-ccm-services-final-report

https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf