Although Medicare has begun paying physicians for offering patients chronic care management (CCM), surveys suggest that providers are struggling with physician engagement, patient education, efficient processes and regulatory compliance.
To bill for CCM services, practices must offer 24/7 access to care management services, a platform for direct patient-practitioner communication and the ability to manage transitions between providers and settings. CCM provides 20 minutes of monthly non-face-to-face care management services for beneficiaries with two or more chronic conditions, helping to manage their conditions, risk factors, medication adherence, and coordination of care with other providers.
Many provider groups have started outsourcing the CCM functions to third parties and integrating those organizations’ technologies with their EHR. For instance, the Central Virginia Coalition of Healthcare Providers (CVCHiP), a Medicare shared savings accountable care organization, has selected Smartlink Mobile Systems to provide its CCM services.
Lerla Joseph, M.D., CEO and chair of 42-physician CVCHiP, said most of the ACO’s physicians have not experimented with CCM yet, but the ones that have found it difficult to implement. “I have a small practice, with two physicians and one nurse practitioner,” she said. “We looked at doing this ourselves when Medicare first implemented the code for chronic care management, but having the right technology and the personnel in the office to do it, and managing the care plan was too challenging for us,” she said. “Even though we dipped our toes in the water, we realized it was way too much for us.
Smartlink’s CCM solution will be used to risk-stratify patients, coordinate referrals, ensure that patients consistently receive high-quality care, and make sure that opportunities for early intervention are recognized.
Practically all the CCM functionality will be outsourced to Smartlink, she said. “We reviewed several companies in terms of care plan, coordination of care, technology, and after reviewing several, the executive committee of the ACO decided to go forward with Smartlink. Again, the tech is there.
She said the ACO’s executive committee chose Smartlink because of its 24x7 availability and capability to text-message patients. “Some of our patients are challenged in terms of access to computers,” she said, “but they do have smartphones. Also, while most of our practices had 24x7 phone coverage, but they didn’t have access to information. With the Smartlink technology, our physicians who are on call can access information for the CCM patients.”
Three of the ACO’s practices have spent the past several weeks getting set up to sign up patients for CCM. They had to get Direct messaging addresses to be able to send and receive messages to Smartlink, using Surescripts as the health information service provider.
“We are set up so that when I send in a referral for CCM, it goes directly to Smartlink,” Joseph said. “There is no faxing involved.”
In some ways, the CCM program is seen as a way to help providers transition to MIPA and MACRA. “We have looked at some of the key indicators for success in ACOs, and care coordination is one of them,” Joseph said. “At the same time, our physicians need to be able to meet the quality metrics. The total cost of healthcare is something they have to grapple with. When you have a program with chronic care management, you are looking at the quality but you are also managing the cost by making sure those patients are getting in the right place at the right time and hopefully decreasing utilization of the emergency room and hospital. Our providers will reap the benefits from having access to this when ordinarily on a small individual basis they would not have embarked upon this.”
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