Chronic care management codes

Coordinating the care of patients with chronic diseases is essential if we are to improve patient care, enhance population health, and reduce health care costs. Care coordination assists the patient's team of providers in making the right diagnostic and therapeutic choices, avoids duplication of services, and facilitates incorporating patient preferences regarding goals of care and socioeconomic determinants of health into the care plan.1

Analysis of 2012 Medicare data found that two-thirds of Medicare beneficiaries older than 65 had multiple chronic medical conditions. More than 41% of the $324 billion spent on traditional fee-for-service Medicare went to the 15% who had at least 6 long-term conditions. In 2010, in three-quarters of the patients with the most costly care, one of the diagnoses was Alzheimer disease (AD).2

The number of people with AD and other chronic neurologic conditions will grow as the mean age of our population increases. Medicare's reimbursement policies have a major effect on the care management services available to such patients and their families.3

Neurologic care consists mainly of cognitive services, not procedures.3 Many of our patients have chronic neurologic illnesses. We need to monitor their progress, balance the risks and benefits of testing and treatment, and coordinate the care they receive at home or in the assisted living facilities or nursing homes where they reside. These encounters demand extended patience and skilled management. Our encounters of care are infrequently curative. Many patients seen by family physicians, internists, and internal medicine subspecialists are also managed over the long term, not cured. Recognizing these “critical components” and the need for “supporting primary care,” the Centers for Medicare & Medicaid Services (CMS) launched their Chronic Care Management (CCM) initiative in 2015. Essentially, additional payment is conditionally available for “non-face-to-face” chronic disease care.

In this issue of Neurology® Clinical Practice, Nuwer4 provides us with a detailed description of CCM services and gives us a toolkit to successfully provide these services to our patients. Nuwer and other American Academy of Neurology Medical Economics and Management Committee members have a long track record of instructing neurologists in how to interpret and navigate the sometimes-dense CMS policies and regulations. Nuwer's table, case example, and key suggestions deserve the close attention of those who wish to understand and participate in CCM. The scope of his article is not to address whether neurology practices will find the CCM initiative rewarding and worthy of their energies. We will take up some aspects of these questions.

Health care policymaking travels uncertain, difficult, and politically gridlocked pathways.5,6 Fundamental reform efforts leading to cost-effective single-payer care have failed repeatedly. The CMS, with no legislative powers of its own, is constrained by rising costs; demands by empowered providers, patients, lobbyists, and committees; and bicameral disagreements. It has the difficult task of administering a vast agency with many stakeholders. The CMS has launched initiatives, audits, reviews, and quality improvement measures with mixed success.7 An example is the excessive reliance placed on process measures that are poorly linked to improved health outcomes.8

The origins and intent of CCM are laudable. Configured to help primary care, the CMS didn't structure CCM with neurologists in mind. In Nuwer's case example, CCM will work. But how often do we care for patients with 2 chronic neurologic conditions without comorbidities such as diabetes, osteoporosis, emphysema, hypertension, or vascular disease? If our patient has Parkinson disease and diabetes or dementia and chronic obstructive pulmonary disease, are we able to confidently manage him or her? Some neurologists will want to provide principal care, but many others will not, making these codes less attractive to most neurologists. More than one provider cannot bill for CCM. For those of us who want to provide principal care, would we be willing to negotiate with primary care/family physicians as to who qualifies for primacy as the CCM caregiver?9 Do our practices have the infrastructure to provide 24/7 care for just a few of our patients who have only 2 neurologic conditions? Is the additional payment sufficient to compensate us for the administrative hassles and practice infrastructure needed to qualify for participation in this program? Only time and experience will tell. For those of us electing to bill Medicare and other insurers for CCM, Nuwer's guide will be indispensable.

As currently designed, CCM reimbursement is a minor incentive. The program is unlikely to transform care. It has the potential to become another process-heavy initiative with limited impact.8–11 Two modifications might better position it for more widespread success. First would be to allow more than one provider to bill for management of patients with certain qualified chronic conditions.10 Second would be to increase reimbursement for these services untethered from copayments. Perhaps instead of their usual practice of following Medicare policies, third-party insurers could take the lead in improving CCM services by instituting these changes.

As CMS's CCM program is currently structured, the population of patients with multiple chronic diseases that most neurologists would want to care for in this program is very small. The nettlesome requirements for participating in the program may dilute the appeal of the rewards.

The biggest advance in the CCM program is not in the details of the current program itself but in the major shift in CMS policy that authorizes reimbursement for non-face-to-face outpatient encounters. This may evolve into policies that allow reimbursement for telemedicine and remote monitoring services. Payment for such services, especially useful for patients with limited mobility or living in isolated areas, would markedly transform management for patients with chronic neurologic conditions by improving access to timely and affordable care.

STUDY FUNDING

No targeted funding reported.

DISCLOSURES

S. Satya-Murti has participated in telephone consultations and/or in-person medical advisory board meetings for United BioSource Corporation UBC, Simon-Kucher consultants, AstraZeneca, Avalere LLC, Evidera consulting group, Covidien, Michael J. Fox Foundation, Foley Hoag LLP, Baxter, and Abiomed; has received funding for travel from United BioSource Corporation UBC, AstraZeneca, Avalere LLC, Evidera consulting group, Covidien, Michael J. Fox Foundation, Foley Hoag LLP, and Baxter; serves on the editorial board of Neurology: Clinical Practice; served on the American Academy of Neurology Payment Policy Subcommittee; and served as panelist and later (2010–2011) Vice-Chair CMS-MEDCAC (Medicare Evidence Development and Coverage Advisory Committee). For the duration of the MEDCAC meeting, usually 1–2 days, S. Satya Murti was considered an SGE (Special Government Employee). N.A. Busis has received honoraria for speaking at American Academy of Neurology courses. Full disclosure form information provided by the authors is available with the full text of this article at http://cp.neurology.org/lookup/doi/10.1212/CPJ.0000000000000172.

Correspondence to: saty.murti@gmail.com

Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at http://cp.neurology.org/lookup/doi/10.1212/CPJ.0000000000000172.