Chronic Care Management for Medicare

The majority of Americans have at least one chronic medical condition. Those conditions not only increase how much you spend on health care, they can also have an impact on your quality of life. This is why Medicare created the Chronic Care Management (CCM) program.

This article will take a close look at the Chronic Care Management program and will show you why you may want to sign up.

The Frequency of Chronic Conditions

The Centers for Disease Control and Prevention reports that about 60% of adults in the United States have at least one chronic disease. When you break it down by age, 78% of people 55 and older have one or more chronic diseases, 47% have two or more, and 19% have three or more.

The number of people reaching Medicare age has been increasing since World War II. This is due to an increase in births from 1946 to 1964, referred to as the Baby Boom. By 2030, more than 20% of the U.S. population will be 65 or older. With that comes an expected rise in chronic conditions.

People with chronic medical conditions are likely to use more healthcare services than people without them. They may need more frequent follow-up visits with their doctors, hospital stays, referrals to specialists, tests, and medications.

The Cost of Chronic Conditions

In 2020, health care cost in the United States reached $4.1 trillion. In 2016, chronic disease was responsible for $1.1 trillion of direct healthcare costs, about 6% of the nation's GDP at that time. When indirect costs were taken into account in 2016, the cost for chronic conditions rose to $3.7 trillion.

The most common chronic conditions are dyslipidemia (high “bad” LDL cholesterol and/or low “good” HDL cholesterol), hypertension (high blood pressure), osteoarthritis, and diabetes. The most expensive ones are diabetes, Alzheimer’s disease, and osteoarthritis.

Other conditions are more likely to be associated with a need for hospital care. The Hospital Readmission Reduction Program was created to decrease the risk for hospital stays from common conditions like chronic obstructive pulmonary disease (COPD) and heart failure.

Where Routine Follow-Ups Fall Short

Many people have their medical conditions managed by their primary care physician, but specialists can take on that role too. Follow-up visits, depending on the condition, are often scheduled every few months to annually.

Coordination of care is key. Unfortunately, there can be breaks in communication when multiple providers are involved in your care or if you are hospitalized outside of your provider network. It can be difficult for your provider to give quality care if they do not know what has happened since your last visit.

From a patient perspective, this can lead to mixed messaging. It may not be clear which medications you should take if different providers make changes without communicating with each other. Not only that, healthcare costs can go up if tests are repeated unnecessarily.

Eligibility for Chronic Care Management

The Chronic Care Management program was created by Medicare to close those communication gaps. It also looks to give 24/7 access to care so that people with chronic conditions have better health outcomes.

To be eligible for the program, you must be enrolled in Medicare Part B and have two or more chronic conditions. Medicare defines these as conditions expected to last at least 12 months or, if you are at the end of life, as long as you live.

Those conditions put you at risk for disease complications, flare-ups, functional decline, or even death. Simply put, the disease affects your quality of life and is expected to get worse over time if not properly treated.

How Chronic Care Management Works

The CCM program starts with a face-to-face visit with your healthcare professional—either a physician, certified nurse-midwife, clinical nurse specialist, nurse practitioner, or physician assistant.

A comprehensive care plan will be developed that will then be monitored monthly without needing you to come in for a face-to-face visit each month. Your doctor will still see you for your regularly scheduled office visits.

Not only will your provider address your chronic conditions each month, but they will also coordinate care with pharmacies and other providers. This assures you get refills on time and that you understand any changes to your medical condition or care plan.

They will also manage any care transitions when they occur, for example, when you go to a hospital or skilled nursing facility.

The goal is to provide continuity of care and address your medical, functional, and psychosocial needs to keep you healthy.

This could mean making sure you have equipment and services available at home, arranging transportation to make sure you get to all your medical appointments, or setting you up with community resources to address any social determinants of health.

Better yet is your access to care. Health professionals in the program have to provide more than one way to get in touch with them, whether by an electronic patient portal, telephone, or email. They must also be available 24/7 for emergency care.

Their office will not necessarily be open around the clock, but there will always be someone on call to answer your questions and direct you to emergency care if and when the office is closed.

Benefits of Chronic Care Management Program

People who participate in the Chronic Care Management program were 2.3% less likely to need emergency room or observation care in the hospital, according to one evaluation. Their risk for inpatient hospitalization decreased by 4.7%.

Specifically, hospitalizations related to congestive heart failure, dehydration, diabetes, and urinary tract infections were statistically reduced. People also reported being more satisfied with their care.

Overall, the Chronic Care Management program saves Medicare $74 per patient per month or $888 per patient per year. These savings were attributed to the decreased need for more expensive services (hospital care and skilled nursing care) and improved efficiencies in care.

With more than 61.2 million people on Medicare in 2020 (37.7 million on Original Medicare and 23.5 million on Medicare Advantage), and half of them having two or more chronic conditions, there are billions of dollars in potential savings for Medicare. More importantly, the improvements in care have a real impact on quality of life.

Should You Enroll in Chronic Care Management?

The CCM program has a lot to offer, but it is not free. The time your healthcare professional spends coordinating care each month and reviewing your records will be billed to Medicare.

The time spent on these services must be a minimum of 20 minutes, which is, on average, the amount of time they would normally spend with you in a face-to-face office visit.

Chronic Care Management services cost approximately $42 per month, though prices may vary based on where you live. Medicare reimburses the physician 80%, and you will pay a Part B 20% coinsurance. On average, that would be $8.40 each month.

Your provider may charge more if they spend more time on your care, up to an hour, or if the care is more complicated.

Many Medicare beneficiaries are on fixed incomes and may not be able to afford this monthly charge. What’s important to know in these and all cases is that your healthcare professional cannot sign you up for these services without your permission.

If you have a Medicare supplement plan, also known as a Medigap plan, it may pay your Part B coinsurance for you. Likewise, if you are eligible for certain Medicare Savings Programs, you will not need to pay out of pocket for these services.

Summary

Chronic Care Management is an effective program developed to improve care coordination for the millions of Medicare beneficiaries with chronic medical conditions. It improves access to care, increases patient satisfaction, and decreases long-term medical complications.

A Word From Verywell

Chronic Care Management opens up time in your doctor’s schedule to ensure you get the care and attention you need. If you can afford the monthly fee, it may be worth considering. If you cannot, you may want to look into Medicare Savings Programs to see if you can save on your Medicare expenses. Talk to your doctor about your options.