Abstract
Background:
The Centers for Medicare and Medicaid Services (CMS) introduced Chronic Care Management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics.
Methods:
We used 2014–2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015; 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics.
Results:
The proportion of beneficiaries with two or more chronic conditions receiving CCM service increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2–5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service.
Conclusion:
We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.
INTRODUCTION
As the aging population in the United States grows, healthcare systems are faced with the challenge of improving the quality of care for older adults while managing healthcare costs.1 The significant burden of chronic disease care costs is a major contributing factor to the nation’s $4.1 trillion annual health care costs.2 To effectively manage chronic diseases, care coordination and ongoing monitoring of patients’ health conditions is critical.3,4
On January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) introduced Chronic Care Management (CCM) services to compensate non-face-to-face clinical staff time each month to enhance care coordination and continuity of care (Supplementary Appendix S1).5,6 CCM services include structured recording of patient health information, keeping comprehensive electronic care plans, managing care transitions and other care management services, and coordinating and sharing patient health information promptly within and outside the practice.5 Those living with an expected 12+ month duration of multiple chronic conditions or those whose multiple chronic conditions put them at significant risk of death are eligible.5 On January 1, 2017, CMS expanded coverage to compensate for longer non-face-to-face clinical staff time. In January 2019, CMS further expanded coverage for non-face-to-face physicians’ or other qualified healthcare professionals’ time.
Early reports suggest that despite the intention of CCM service, its adoption remains low, ranging from 1.2% in 20157 to 4% in 20198 of the eligible patients. However, previous studies4,7–12 did not examine whether patients who are most in need received CCM services. These patients typically have a high comorbidity burden, frailty, and dementia and are dually eligible for Medicare and Medicaid, requiring a coordinated and multidisciplinary approach. Additionally, previous studies have not identified geographic differences using recent data. Examining geographic variation in CCM service utilization may help identify and address barriers in underserved regions, thereby increasing CCM service adoption.
To fill this knowledge gap, we conducted a retrospective study to examine the utilization of CCM service from 2015 to 2019 by geographic region, sociodemographic and clinical characteristics among potentially eligible Medicare fee-for-service beneficiaries.
METHODS
Data Sources and Study Population
This study used Medicare claims data from a 5% random sample of fee-for-service beneficiaries between January 1, 2014, and December 31, 2019. The Advarra Institutional Review Board approved this study, and a waiver of informed consent was obtained. To select beneficiaries who were potentially eligible for CCM service (Supplementary Figure S1), on January 1 of each year from 2015 to 2019, we identified Medicare beneficiaries who 1) lived in the United States (excluding Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands); 2) were 65 years or older; 3) were enrolled for at least one month in Medicare Part B; and 4) had two or more chronic conditions from the Chronic Conditions Data Warehouse list (Supplementary Table S1).
Identification of CCM Service
CCM service claims were identified from Medicare Part B provider file (carrier file) using the Current Procedural Terminology (CPT) codes 99490, 99491, and 99487 to capture initial visits. We did not include CPT code 99489, which is only reimbursable after initiation of CCM service code 99487 since it represents an added-on code to reimburse physicians for the extra time (i.e., 30 minutes) it takes to coordinate care for patients in complex care situations.13 Before starting CCM service, an initial visit is necessary for patients who have not seen the billing practitioner within the past year.5 An initiation visit can be a comprehensive face-to-face Evaluation and Management (E/M) visit, Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE), or comprehensive assessment of and care planning for initiating CCM service.5 We excluded CCM claims without an E/M visit (CPT codes 99201–99205, 99211–99215), AWV visit (CPT codes G0438, G0439), IPPE (CPT code G0402), and comprehensive assessment of and care planning for initiating CCM service (CPT code G0506) within the past year (Supplementary Figure S2). Because only one CCM claim per month is allowed, in the small number of cases with multiple CCM claims per month, we retained the claim with higher complexity.
Measurement of Characteristics
The following sociodemographic and geographic characteristics were measured for each year: age (65–69, 70–74, 75–79, 80–84, ≥85 years), sex, race and ethnicity (White, Black, Asian/Pacific Islander, Hispanic, other, unknown), dual eligibility for Medicare and Medicaid, geographic region (states), and selected chronic diseases (cancer, chronic kidney disease, dementia, depression/bipolar disorder, diabetes, heart failure, hypertension, hypothyroidism, ischemic heart disease, peripheral vascular disease, rheumatoid arthritis/osteoarthritis) from the CMS Chronic Condition Data Warehouse files. Additionally, frailty was defined using the Kim Claims-Based Frailty Index (CFI) for each year (robust: <0.15, prefrail: 0.15–0.24, mildly frail: 0.25–0.34, moderately frail: 0.35–0.44, severely frail: ≥0.45).14,15 The CFI was calculated in beneficiaries who were enrolled for the 12 months in Medicare Part A and B for each year. For each CCM claim, we recorded primary diagnosis category (endocrine, nutritional, and metabolic diseases; mental and behavioral disorders; diseases of the circulatory system; diseases of the respiratory system; diseases of the musculoskeletal sys12tem and connective tissue; and other) and provider specialty (internal medicine, family practice, nurse practitioner, cardiology, and others).
Statistical Analysis
We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region (state), sociodemographic characteristics (age, sex, race and ethnicity, and dual eligibility), and clinical characteristics (number of chronic diseases, frailty category, and dementia). We also calculated the total number of CCM claims per beneficiary, and the total number of CCM claims per provider. All analyses were conducted using SAS version 9.4 (Cary, NC. SAS Institute Inc.).
RESULTS
The beneficiaries who received CCM service had a mean (standard deviation) age of 77.2 (7.8) years in 2015 to 77.2 (7.9) years in 2019; the proportion of women was 61.4% to 60.3%; the proportion of White race was 78.9% to 75.7%; and, the proportion of dual4 eligibility was 20.2% to 21.3% (Table 1). Common chronic conditions in the CCM recipients were hypertension (94.4% to 94.1%), rheumatoid arthritis/osteoarthritis (72.4% to 74.6%), ischemic heart disease (65.7% to 63.6%), and diabetes (55.1% to 54.8%). The majority of CCM claims used CPT code 99490, which is reimbursement for the first 20 minutes of clinical staff (100.0% to 93.3%)4 (Supplementary Table S3). The diagnoses recorded in the CCM claims were diseases of the circulatory system (40.6% to 39.6%) or endocrine, nutritional, and metabolic diseases (30.5% to 29.9%). The service was mainly used by providers in internal medicine (48.6% to 41.7%) and family practice (31.6% to 30.0%). The proportion of nurse practitioners (5.5% to 6.4%) and cardiology (5.8% to 6.7%) who rendered the service were slightly increased.
Table 1.
Characteristics of Medicare Fee-For-Service Beneficiaries Receiving Chronic Care Management Service in 2015–20191
| Characteristics | 2015 | 2016 | 2017 | 2018 | 2019 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||
| 11,480 | (100.0) | 22,154 | (100.0) | 31,890 | (100.0) | 37,341 | (100.0) | 38,863 | (100.0) | ||
| Age | |||||||||||
| 65–69 | 2,270 | (19.8) | 4,432 | (20.0) | 6,584 | (20.6) | 7,310 | (19.6) | 7,387 | (19.0) | |
| 70–74 | 2,532 | (22.1) | 4,994 | (22.5) | 7,304 | (22.9) | 8,796 | (23.6) | 9,148 | (23.5) | |
| 75–79 | 2,401 | (20.9) | 4,589 | (20.7) | 6,581 | (20.6) | 7,706 | (20.6) | 8,105 | (20.9) | |
| 80–84 | 1,985 | (17.3) | 3,718 | (16.8) | 5,290 | (16.6) | 6,270 | (16.8) | 6,604 | (17.0) | |
| 85–89 | 1,443 | (12.6) | 2,771 | (12.5) | 3,733 | (11.7) | 4,372 | (11.7) | 4,492 | (11.6) | |
| 90+ | 849 | (7.4) | 1,650 | (7.4) | 2,398 | (7.5) | 2,887 | (7.7) | 3,127 | (8.0) | |
| Sex | |||||||||||
| Men | 4,427 | (38.6) | 8,552 | (38.6) | 12,425 | (39.0) | 14,627 | (39.2) | 15,442 | (39.7) | |
| Women | 7,053 | (61.4) | 13,602 | (61.4) | 19,465 | (61.0) | 22,714 | (60.8) | 23,421 | (60.3) | |
| Race and ethnicity | |||||||||||
| White | 9,057 | (78.9) | 17,332 | (78.2) | 24,543 | (77.0) | 28,540 | (76.4) | 29,417 | (75.7) | |
| Black | 1,138 | (9.9) | 2,296 | (10.4) | 3,338 | (10.5) | 4,044 | (10.8) | 4,011 | (10.3) | |
| Asian/Pacific Islander | 266 | (2.3) | 676 | (3.1) | 1,066 | (3.3) | 1,286 | (3.4) | 1,531 | (3.9) | |
| Hispanic | 867 | (7.6) | 1,525 | (6.9) | 2,355 | (7.4) | 2,668 | (7.1) | 2,960 | (7.6) | |
| Other | 92 | (0.8) | 191 | (0.9) | 299 | (0.9) | 378 | (1.0) | 447 | (1.2) | |
| Unknown | 60 | (0.5) | 134 | (0.6) | 289 | (0.9) | 425 | (1.1) | 497 | (1.3) | |
| Dually eligible for Medicare and Medicaid | |||||||||||
| Yes | 2,316 | (20.2) | 4,211 | (19.0) | 6,319 | (19.8) | 7,633 | (20.4) | 8,265 | (21.3) | |
| No | 9,164 | (79.8) | 17,943 | (81.0) | 25,571 | (80.2) | 29,708 | (79.6) | 30,598 | (78.7) | |
| Chronic condition | |||||||||||
| Cancer | 285 | (2.5) | 574 | (2.6) | 905 | (2.8) | 1,058 | (2.8) | 1,131 | (2.9) | |
| Chronic kidney disease | 4,344 | (37.8) | 9,159 | (41.3) | 14,653 | (45.9) | 18,485 | (49.5) | 20,191 | (52.0) | |
| Dementia | 1,037 | (9.0) | 1,911 | (8.6) | 2,733 | (8.6) | 3,388 | (9.1) | 3,668 | (9.4) | |
| Depression/bipolar disorder | 3,831 | (33.4) | 7,416 | (33.5) | 11,005 | (34.5) | 13,398 | (35.9) | 14,763 | (38.0) | |
| Diabetes | 6,325 | (55.1) | 11,960 | (54.0) | 17,211 | (54.0) | 20,315 | (54.4) | 21,301 | (54.8) | |
| Frailty (CFI ≥ 0.25)2 | 2,152 | (22.6) | 4,151 | (22.6) | 5,732 | (21.6) | 6,810 | (22.1) | 7,546 | (23.3) | |
| Heart failure | 4,562 | (39.7) | 8,521 | (38.5) | 12,036 | (37.7) | 14,393 | (38.5) | 15,123 | (38.9) | |
| Hypertension | 10,841 | (94.4) | 20,955 | (94.6) | 30,030 | (94.2) | 35,186 | (94.2) | 36,582 | (94.1) | |
| Hypothyrodism | 4,526 | (39.4) | 8,599 | (38.8) | 12,251 | (38.4) | 14,543 | (38.9) | 15,440 | (39.7) | |
| Ischemic heart disease | 7,537 | (65.7) | 14,240 | (64.3) | 20,180 | (63.3) | 23,779 | (63.7) | 24,711 | (63.6) | |
| Peripheral vascular disease | 4,273 | (37.2) | 7,917 | (35.7) | 11,396 | (35.7) | 14,008 | (37.5) | 15,059 | (38.7) | |
| Rheumatoid arthritis/osteoarthritis | 8,312 | (72.4) | 16,067 | (72.5) | 23,381 | (73.3) | 27,757 | (74.3) | 29,009 | (74.6) | |
Data shown are number (percentage)
CFI: Claim-based Frailty Index; The CFI was calculated in beneficiaries who were enrolled for the 12 months in Medicare Part A and B for each year (118,518 in 2015; 122,268 in 2016; 116,154 in 2017; 114,008 in 2018; 115,071 in 2019).
Among fee-for-service Medicare beneficiaries, approximately 75% had two or more chronic conditions (Supplementary Figure S1). The proportion of beneficiaries with two or more chronic conditions receiving CCM service increased from 1.1% in 2015 to 3.4% in 2019, and the number of CCM claims per 1000 eligible beneficiaries increased from 35.1 in 2015 to 168.0 in 2019 (Supplementary Table S2). The increase in CCM use from 2015 to 2019 was more pronounced in the southern region (Figure 1). Georgia reported the highest utilization at 6.1%, followed by Texas, Florida, and Mississippi, each at a rate of 5.8% in 2019 (Figure 1). In comparison, New Hampshire, Montana, North Dakota, Alaska, and Vermont had lower rates (less than 0.5%) (Figure 1). Similarly, the increase in the number of CCM claims per 1000 eligible beneficiaries was concentrated in the southern region (Supplementary Figure S3).
Figure 1.
Proportion of Eligible Medicare Fee-For-Service Beneficiaries Receiving Chronic Care Management Service by Geographic Region.
Throughout the study period, the use of CCM service was higher in older age (65–69 years vs ≥85 years: 1.0% vs 1.2% in 2015; 2.9% vs 4.2% in 2019), women (women vs men: 1.1% vs 1.0% in 2015; 3.5% vs 3.3% in 2019), Hispanic and Black beneficiaries compared to White beneficiaries (Hispanic and Black vs White: 1.5% and 1.3% vs 1.0% in 2015; 5.1% and 4.7% vs 3.2% in 2019), and dually eligible beneficiaries (dually eligible vs non-dually eligible: 1.4% vs 1.0% in 2015; 5.1% vs 3.2% in 2019) (Figure 2 and Supplementary Table S2). CCM utilization increased with the number of chronic conditions (2–5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019), the degree of frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019), and the diagnosis of dementia (dementia vs no dementia: 1.5% vs 1.0% in 2015; 5.7% vs 3.3% in 2019) (Figure 3 and Supplementary Table S2).
Figure 2. Proportion of Eligible Medicare Fee-For-Service Beneficiaries Receiving Chronic Care Management Service by Sociodemographic and Clinical Characteristics.
Frailty categories were defined using the claims-based frailty index as robust: <0.15, prefrail: 0.15–0.24, mildly frail: 0.25–0.34, moderately frail: 0.35–0.44, severely frail: ≥0.45.
Figure 3. Proportion of Eligible Medicare Fee-For-Service Beneficiaries Receiving Chronic Care Management Service by Clinical Characteristics.
Frailty categories were defined using the claims-based frailty index as robust: <0.15, prefrail: 0.15–0.24, mildly frail: 0.25–0.34, moderately frail: 0.35–0.44, severely frail: ≥0.45.
Among those who received CCM services in 2015, 64.1% of beneficiaries received the service for 3 months or less and only 3.7% received the service for 10 months or more (Figure Supplementary S4). In 2019, more beneficiaries received longer service such that the proportion of beneficiaries receiving the service for 3 months or less decreased to 46.6% and those who received service for 10 months or more increased to 15.8% (Figure Supplementary S4). Nearly one out of five recipients did not continue CCM service after the initial service (33.3% in 2015; 21.6% in 2019) (Figure Supplementary S4). Among the providers who offered CCM services, the proportion of providers who submitted claims for 10 to 49 CCM services increased from 23.9% in 2015 to 34.0% in 2019, which is the most common (Figure Supplementary S4). Fewer than 10% of the providers who offered CCM services submitted more than 50 CCM claims per year (4.0% in 2015; 8.1% in 2019) (Figure Supplementary S4).
DISCUSSION
From 2015 to 2019, nearly 75% of Medicare fee-for-service beneficiaries were eligible for CCM yet the overall utilization rate remained low (1.1% in 2015 to 3.4% in 2019). We found that the utilization of CCM service increased, particularly for Medicare beneficiaries who were older, Black or Hispanic race and ethnicity, dually eligible for Medicare and Medicaid, with greater burden of comorbidities and frailty, and living in the southern region. While these trends are desirable, nearly half of CCM recipients (64.1% in 2015 to 46.6% in 2019) received the service for only three months or less and one out of five recipients did not continue CCM service after the initial service. Considering that the CCM-eligible conditions are expected to last at least 12 months and significantly increase the risk of mortality and poor quality of life, our results suggest potential for further improvement in the delivery and duration of CCM service.
Older adults with multiple chronic conditions have complex health needs and higher healthcare utilization.16,17 As a result, they are more likely to benefit from care coordination9 and continuity of care with their primary care providers.18 CCM services may be used more often in beneficiaries who have greater burden of comorbidities and frailty, because they are more likely to require more care coordination between office visits.9 To the best of our knowledge, this paper is the first to examine the CCM services utilization by frailty and burden of comorbidities.
There are several potential reasons for the overall low utilization and lack of continuity in CCM service delivery. From the beneficiary’s perspective, cost sharing for CCM service may be burdensome without supplemental insurance or Medicaid coverage.19 CCM service is fully covered for those who are dual eligible for Medicare and Medicaid. In fact, we observed higher CCM service use among beneficiaries who were dually eligible for Medicare and Medicaid services than those who were not. From the provider’s perspective, the reimbursement level for CCM service may be insufficient to fully support the clinical staff necessary for implementation. A previous study estimated that at least 131 patients would need to be enrolled to employ one full-time registered nurse to provide CCM service.20 In our study, fewer than 10% of the providers who rendered CCM services submitted more than 50 CCM claims per year. Moreover, primary care providers and clinical staff may not be adequately trained to identify eligible patients,21 provide care coordination,22 or manage health status for medically complex older adults23 such as those with frailty, and complete documentation required for reimbursement.21 Some guidelines might be needed to outline the steps for providing CCM service.
Our study found higher use of CCM service among Hispanic or Black beneficiaries than those who are White or of other racial groups. A previous study conducted in the New England region reported that White race was associated with a higher likelihood of receiving CCM service than other races and ethnicities.9 However, in another study comprising a national sample of Medicare fee-for-service beneficiaries reported results consistent with ours.8 We also observed that the CCM uptake was higher in the southern region than in other regions, which was also consistent with an earlier study using the 2015–2016 Medicare data.22 When CCM service was introduced in 2015, CMS implemented advanced primary care demonstration projects in several Northeast and Midwest states, such as the Multi-Payer Advanced Primary Care initiative24 (Maine, Michigan, New York, Rhode Island, and Vermont) and the Comprehensive Primary Care initiative (Arkansas, Colorado, New Jersey, New York, Ohio, Oklahoma, and Oregon) (Supplementary Appendix S2).25 From 2017 to 2022, several states implemented the Comprehensive Primary Care Plus (Supplementary Appendix S2).26 Because these enhanced primary care initiatives provided a wide range of services including risk-stratified care management, continuity of care, and care coordination, CCM service could not be concurrently implemented for patients involved in these initiatives.24,25 This may be responsible for the lower uptake of CCM service in the selected Northeast and Midwest regions.
There are a few limitations to our study. First, we used administrative claims to identify potentially eligible patients for CCM service, which may have been inaccurate. This could affect the estimation of the utilization rate. Second, our study population was limited to Medicare fee-for-service beneficiaries; therefore, our findings may not be generalizable to Medicare Advantage beneficiaries. Third, since our database included CCM claims between 2015 and 2019, we were unable to examine the impact of the Coronavirus Disease 2019 pandemic on the CCM service utilization. Non-face-to-face service by providers and clinical staff might have played a more significant role during the period when face-to-face visits had to be limited. Further research is warranted to examine CCM utilization among beneficiaries of Medicare Advantage Plans during the Coronavirus Disease 2019 pandemic, as well as the effect of CCM service on clinical outcomes, healthcare utilization, and total Medicare costs.
In conclusion, despite the large number of Medicare beneficiaries with multiple chronic conditions who may benefit from care coordination and continuity of care, we found that CCM service is being used by a very small fraction of eligible patients and for an only short duration. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.
Supplementary Material
Key Points
From 2015 to 2019, nearly 75% of Medicare fee-for-service beneficiaries were eligible for CCM yet the overall utilization rate remained low (1.1% in 2015 to 3.4% in 2019).
We found that the utilization of CCM service increased, particularly for Medicare beneficiaries who were older, Black or Hispanic race and ethnicity, dually eligible for Medicare and Medicaid, with greater burden of comorbidities and frailty, and living in the southern region.
Nearly half of CCM recipients had the service only for three months or less, and one out of five recipients did not continue CCM service after the initial service.
Why does this paper matter?
Despite the large number of Medicare beneficiaries with multiple chronic conditions who may benefit from care coordination and continuity of care, we found that CCM service is being used by a very small fraction of eligible patients and for a short duration only. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.
Funding:
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG071809–02S1 and K24AG073527, and the Korea Health Technology R&D Project grant through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI21C1234 to Dr. Jang).
SPONSOR’S ROLE
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding sources had no role in the design, collection, analysis, or interpretation of the data, or the decision to submit the manuscript for publication.
FINANCIAL DISCLOSURE
Dr. Kim has been supported by the grants from the National Institute on Aging of the National Institutes of Health for unrelated work. He received personal fees from Alosa Health and VillageMD for unrelated work.
Footnotes
CONFLICT OF INTEREST STATEMENT
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG071809-02S1 and K24AG073527, and the Korea Health Technology R&D Project grant through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI21C1234 to Dr. Jang).
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