Medicare's Chronic Care Management Program Associated With Reduced Growth in Medicare Costs and Better Support of Chronically Ill People

New study shows impact of in-between visit care for people with multiple chronic conditions

The Center for Medicare and Medicaid Innovation (CMMI) released a new study this week that showed that its chronic care management (CCM) program is associated with lower growth in Medicare costs, an enhanced ability to connect patients with community-based resources, and is helping to keep patients out of the hospital.    

CCM is a program launched by the Centers for Medicare and Medicaid Services (CMS) in 2015 to help provide support for patients with multiple chronic conditions in-between their provider visits and episodes of care.  The CCM program created a new Medicare-benefit to support beneficiaries with two or more chronic conditions by providing new “in-between visit” revenue to participating providers, stimulating practices to enhance their focus on goal-directed, person-centered care planning, and to provide “aging-in-place” resources such as proactive care management.

The study showed that participation in the CCM program was associated with a lower growth in total costs to Medicare than the comparison group. Patients in the CCM program had the lower hospital, emergency department and skilled nursing facility costs. Receipt of CCM services was also associated with a reduced likelihood of hospital admission for the ambulatory care sensitive conditions of diabetes, congestive heart failure, urinary tract infection, and pneumonia among CCM beneficiaries, relative to the comparison beneficiaries.  The CCM program was also associated with increased access to advance care planning (10% among CCM participants versus 1% in the general Medicare population). The study authors concluded that “CCM is having a positive effect on lowering the growth in Medicare expenditures on those that received CCM services.”

Dr. William Mills, President and CEO of Chronic Care Management, Inc. said, “The CMMI study performed by Mathematica showed a significant early chronic care management program success. Most notably, patients in the CCM program were more connected to their healthcare providers, had more access to their primary care doctor and better utilized home-based services like home health care, which are helping patients avoid unnecessary hospital and emergency department use. Mills continued, “This study also showed reduced hospitalizations for ambulatory care sensitive conditions among CCM beneficiaries, which is a major focus of the program – to help empower patients and providers with actionable plans that can help keep patients at home, instead of in hospitals.” 

Chronic Care Management, Inc. provides:

  • A comprehensive “in-between episode” chronic care management technology solution as well as practice-integrated clinical staff that together provide complete care management for Medicare, Medicaid, and Commercial beneficiaries to enable doctors to participate in the cutting edge program while enabling providers workflow
  • Chronic care management support for multiple Quality Programs including Accountable Care Organizations (ACO) and the Medicare Shared Savings Program (MSSP), MIPS, Bundled Payments for Care Improvement (BPCI), and others
  • Robust Risk Stratification capability, enabling chronic care management workflow from high to low risk
  • Capture of non-visit revenue via chronic care management codes (CPT 99490, CPT 99487 and CPT 99489) with 3rd-party tested, robust audit trail and time tracking features
  • Support of new Behavioral Health Integration (BHI) program codes, including CPT 99484, enabling in-between episode support of people with behavioral, addiction and mental health conditions
  • Chronic Care Management Professional Hints, which provide evidence-based documentation processes for many chronic medical conditions
  • Business intelligence tools that provide real-time data on CCM revenue and other key performance indicators
  • Advanced scheduling / Call Center support technology to address the continuity of care and community outreach to the patients in between physician visits
  • Comprehensive medication management including home delivery and adherence tools via partner pharmacy

About Chronic Care Management, Inc.

Chronic Care Management, Inc. is a solution-oriented technology and services care management provider. The company’s primary focus is “in-between visit” care management for people with multiple chronic conditions. Headed by William Mills, M.D., a physician with extensive national care management leadership and primary care and geriatrics practice, the company develops and deploys software and clinically integrated care management programs that promote goal-directed, quality collaborative care planning. The solutions bring together healthcare providers, systems, and stakeholders around a central, person-centered care plan that drive positive clinical outcomes for patients and positive financial outcomes for healthcare organizations and payers, including Medicare. Providing fee-for-service healthcare providers a concrete path from volume to value, Chronic Care Management, also empowers organizations who are participating in alternative payment models with a formal platform to foster care coordination, quality measure success attainment, advance care planning, care transitions, medication reconciliation and a number of other success-driving areas.

For more information, or to schedule a product and services presentation, please visit or call toll free: (844) CCM-6500 / (844) 226-6500.

© 2018 Chronic Care Management, Inc. Chronic Care Management Professional Hints and the Chronic Care Management company name with logo are registered trademarks of Chronic Care Management, Inc. All rights reserved.

Press Contacts:

Kathy Lewis

Chronic Care Management, Inc.

(844) 226-6500

Source: Chronic Care Management, Inc