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Roundtable with Suzan Delbene: The impact of cost-sharing for CCM on patients and clinicians

Updated: Aug 12, 2019

On Friday, August 2, the Washington State Medical Association hosted an event with Congresswoman Suzan DelBene (WA 1st District) at the Roosevelt Clinic to discuss her proposed bill to eliminate cost-sharing for Medicare beneficiaries receiving Chronic Care Management (CCM). Clinicians and a patient participated in a round table discussion with the Congresswoman to discuss how the proposed bill would impact patients and care teams who deliver CCM services.

The Clinical Need for Chronic Care Management

Jamie provided a patient view of what is needed from primary care in order to support her in managing a complex autoimmune disease – including coordination of care between multiple specialists, a streamlined care plan, and support with medication management. She also expressed the difficulty of affording health care including expensive medications on a fixed income. She had been working full time prior to her diagnosis and as her condition progressed, she was no longer able to work, limiting her resources.

"Yet, in the traditional fee-for-service payment system, primary care teams do not get reimbursed for the work done outside of visits."

We were fortunate to attend as clinicians and VSSL team members. Along with other clinicians in attendance -- Wayne McCormick, MD, MPH and Kathleen Mertens, DNP, MPH -- we shared that chronic condition management requires a huge amount of between-visit care and that, in primary care, effectively “quarterbacking” the management of chronic conditions mandates a team. While primary care clinicians are skilled at diagnosis and medication prescribing, nurses generally receive more training in self-management support. Behavioral health clinicians who work with patients in non-medication treatment of depression and anxiety, for example, can have a large impact in improving management of chronic conditions through supporting behavior change. Yet, in the traditional fee-for-service payment system, primary care teams do not get reimbursed for the work done outside of visits. Historically, primary care has relied on the revenue from visits in order to fund medical assistants, nurses and social workers, driving up visit volumes, shortening visit times and reducing face-to-face contact with patients.

Policy Supporting Chronic Care Management

In the last decade, the Centers for Medicare and Medicaid Services (CMS) has recognized that fee-for-service payment is inadequate to incentivize and pay for primary care that is comprehensive, coordinated, and continuous, and delivered by a team that leverages all members’ skill sets and training. With the premise that primary care is the nexus of health care delivery with the potential to reduce total costs of care and improve health outcomes, CMS has been introducing programs, including payment mechanisms through CCM codes, to better support and pay for primary care.

The codes were introduced in 2015 as part of the Physician Fee Schedule in order to compensate chronic care management in primary care. CCM regulations are not specific as to who must administer the between-visit care but does require a designated primary care clinician, a comprehensive care plan that is accessible by all care team members, 24/7 access to the care team, medication management and care coordination. Practices can bill CCM for each patient once per month if at least 20 minutes was spent in managing or coordinating care (e.g., communicating with specialists or telephone follow up with a patient). Patients who are insured through Medicare can receive CCM services if they have at least two chronic conditions – which qualifies approximately 67% of Medicare beneficiaries for CCM. Using the CCM CPT code, 99490, primary care practices can be reimbursed approximately $40 per month that the code is billed.

Despite these potential benefits, CCM includes 20% cost-sharing to patients. While most are not charged because either Medicaid or supplemental insurance covers the cost of CCM, cost-sharing is the most significant cause for confusion and discontent with CCM for both patients and providers.

"Direct evaluation and evidence is also needed to validate the intuition that providing more comprehensive, coordinated primary care with expanded access should decrease overall costs of care to CMS."

As we shared at the roundtable discussion, in consenting patients for CCM services, primary care clinicians often will not know if and how much patients might be charged. For example, facility fees tied to clinics affiliated with hospitals may increase cost-sharing. An analysis of CCM found that on average, per patient, primary care practices, billed CCM services 6 months out of the year, meaning it is also difficult for primary care teams to predict which and how many months patients might be billed. Finally, while most patients who are billed directly will generally at most receive bills for $8 per month, this cost can be substantial for older adults with fixed incomes; it is possible that the cost-sharing could disproportionately affect a particularly vulnerable population by excluding those who have supplemental insurance or Medicaid. As more CCM codes are introduced to compensate for higher complexity care, those patients who are subject to the cost-sharing, may receive more expensive bills, placing barriers to accessing high quality primary care.

Though the benefits of removing cost-sharing are clear, the budgetary and program size implications are not. The proposed bill is not budget neutral – if the beneficiary cost-sharing is eliminated from the CCM program, CMS will absorb that 20% cost. Additionally, there is reason to expect that with the removal of this perceived barrier, CMS would also see increased uptake of CCM services. The net impact on CMS budget, and what other provisions enable the agency to take on these added costs, bears discussion and monitoring. Direct evaluation and evidence is also needed to validate the intuition that providing more comprehensive, coordinated primary care with expanded access should decrease overall costs of care to CMS.

As the CCM program continues, we will amass more data regarding impact on total costs of care and outcomes. Until then, we can expect that removing cost-sharing to patients in the CCM program is likely to improve both patient and clinician satisfaction and engagement with an important program.


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