“The cost of healthcare has soared to untenable heights. In the United States, federal healthcare spending is rapidly approaching 20% of GDP. Furthermore, chronic disease is highly prevalent, accounting for nearly 90% of all healthcare spending. Additionally, it costs 3.5 times more to treat chronic diseases than it does other conditions, and they account for 80% of all hospital admissions. In recent years, rapid advancements in healthcare delivery models and low-cost wireless communication have spurred optimism in finding cost-effective, value-enhancing solutions to these issues.”
Improving chronic care management services is crucial to the success of the independent medical practice for many reasons. The first priority, of course, is to be able to provide the highest level of professional care to maintain and sustain patient health. In fact, The Centers for Medicare & Medicaid Services (CMS) is recognizing more and more that Chronic Care Management, or CCM, is a critical component of primary care. The COVID-19 pandemic focused a spotlight on the need for increased remote care capabilities, and CMS revised some of its reimbursement regulations in response.
Despite the revisions, however, chronic or long-term patients can still cause a severe drain on the physical and financial resources of the practice. Patients with chronic conditions must be managed closely, with regular monitoring of vital signs, and glucose levels, as well as heart and lung functions. Staff must input this data into the EHR, analyze it, and communicate with the patient if action needs to be taken. Consistent attention is required for long periods of time, months or even years, and all of it must be accurately coded and billed, so the practice can be compensated for its efforts. Chronic Care Management covers a wide range of patient circumstances, including:
In addition to specifying health conditions, Chronic Care Management includes a number of reimbursable activities set out by CMS:
One question independent practices were forced to face during COVID was how to provide such high levels of chronic care management on a remote basis. Fortunately, ever-evolving technologies continue to make the process efficient and cost-effective:
Telehealth solutions increase the ability of your practice to remotely deliver in-home patient care. They allow you and your medical staff to quickly and easily initiate telehealth video and secure text conversations and maintain logs of those chats and videos for billing and audit purposes.
Amazing Charts now offers the capability to add external remote care services to your patient care kit by adding remote staff, or contracting out existing staff, to reduce labor costs while maintaining patient continuity. In cases of CCM, the Virtual Preventative Care Assistant can augment staff in support of televisits.
Make the most of technology by using your EHR to support your Chronic Care Management Initiative. Components of a comprehensive EHR include easy charting capabilities, templates, e-Prescribing, scheduling, and a patient portal.
Part of the telemedicine spectrum, RPM incorporates a variety of wired or wireless devices that help to capture patient data and transmit it to the medical caregiver for analysis. These might include wearable or implantable devices, blood pressure cuffs, glucose meters, biosensors or pulse oximeters. Other devices allow patients to transmit user-entered data or facilitate access to secure record storage. Abnormal readings should be flagged for review.
Once you have the technology in place for a Chronic Care Management initiative, your independent medical practice will also need to take other components into consideration, including:
Patients must have a designated physician/NP as their clinician. 24/7 access is required to address urgent care needs. Decide who in your practice will be tasked to the CCM team and discuss scheduling concerns.
Both patients and team members need to be educated about the benefits of participating fully in the chronic care management program.
Obtain and maintain documented patient consent to participate in the process, being sure to adhere to all CMS, state, data security and HIPAA guidelines. Include full disclosure of how any technology will be used, liability and malpractice procedures, billing and insurance information, and details on data security measures and potential risks to patient privacy.
Your billing department may need to take a refresher on the latest CMS codes for CCM cases, or you may want to consider a Medical Billing Service that can handle the hassle of billing for you.
In the shift from practice-centric to patient-centric delivery models, remote care initiatives can help the independent practice provide increased access to care for the most at-risk populations. Because it involves changes for both staff and patients, guiding principles to keep in mind when implementing a chronic care management initiative at your independent practice should include:
“Remote Monitoring a Valuable Tool for Reducing Heart Failure Readmissions And Hospitalizations”
~ Teresa Sieck, PhD, Physicians Practice, July 22, 2021
According to a recent article in Physicians Practice, heart failure accounts for some 11 million physician visits each year; however, new technologies enable more effective Remote Patient Monitoring and Chronic Care Management without requiring patients to even leave their home. This process became even more crucial during COVID, as evidenced by the updated remote patient monitoring reimbursement rules from CMS. In addition to helping independent practices continue to monitor patients during the pandemic, these new codes provide further financial incentives for care providers to adopt this new technology.
In the article Rachel Robinson, director of quality and risk management for MercyOne Iowa Heart Center, revealed that the Center had enrolled 450 patients in a remote monitoring study. Results showed improvement in lower readmission and hospitalizations, as well as increased use of directed care therapies for heart treatment.
Remote care can empower patients to better manage their health by participating more fully in the health care process. Remote care services can provide the independent practice with a fuller view of a patient’s health over time, increase its visibility into a patient’s adherence to a treatment, and enable timely intervention before a costly care episode.
Clinicians and care providers can strengthen their relationships with, and improve the experience of, patients by using the data sent to them, and their conversations or messaging, to develop a personalized care plan and engage in joint decision-making to foster better outcomes.
CCM refocuses attention on providing services that lead to better population health. Along with improved care, it also provides many benefits to the independent medical practice:
Improved care coordination and increased patient involvement leads to better health outcomes.
Practices can receive CMS reimbursement for providing monthly CCM services per the stated guidelines.
A systematic approach to Chronic Care Management enables the practice to operate at the highest levels of efficiency.
Encouraging patients to use CCM services gives them the support and motivation they need to follow good health habits between office visits.
Appointment and test reminders, increased education and access to personal information gives patients a feeling they can do something positive in working with a medical care team to improve their health.
Making CCM services available helps improve office efficiency, which leads to improved patient satisfaction and increased patient loyalty.
A better-performing program that leads to positive outcomes for some of the most challenging cases can make staff members feel better about their jobs, leading to increased retention.
Patients with higher control over chronic conditions can decrease emergency room visits and hospital stays, thereby reducing costs for insurance providers.
CCM provides another method of sustaining and growing an independent practice without adding additional facilities or requiring an increase in necessary personnel. It provides additional resources and care for high-need patients, while allowing providers to continue providing care to the balance of their patient population.
Today’s patients expect a different kind of healthcare experience. Remote care makes it easier to follow-up with chronic care patients, and make sure everything is going well. Most importantly, taking advantage of the latest in remote care services will not only help your practice thrive, but remain independent in the times ahead.