For Providers

Statistics.

Health care spending in the US increased by 9.7% in 2020, reaching $4.1 trillion, of $12,530 per person. Healthcare spending accounted for 19.7 percent of the nation’s GDP.  

90% of the nation’s annual health care costs are for people with chronic and mental health conditions.

According to Medicare claims data, CCM reduces unnecessary hospital visit by 4.7%, ED visits by 2.3% and manages health problems with an extra level of care. In turn, patients are healthier, more connected, and save on healthcare costs annually.

In 2014, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for Chronic Care Management services provided to Medicare patients with two or more chronic conditions.

CCM services can reduce the average monthly per-patient cost by $74 and still bring revenue to physician practices.

(Statistical Sources) 

CMS -https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical

CMS - https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

CDC-https://www.cdc.gov/chronicdisease/about/costs/index.html

Solutions.

Chronic Care Management Solutions (CCMS) has a mission to continually improve patient quality of care and satisfaction.  Offering team-based care to improve patient outcomes and close care gaps, while increasing your practice’s revenues, including reimbursement for the non-face-to-face work your office is already doing.  

Chronic Care Management Solutions will ultimately help to close gaps in care and improve patient outcomes by:

  • Assisting the practice with enrollment to maximize participation

  • Identifying patient needs and assist with appointments and reminders

  • Tracking preventative services and recommend quality measures

  • Assisting with medication refills and reconciliation

  • Educating and increasing patient awareness

  • Coordinating referrals

  • Documentation/reporting of changes in health status and collaboration with provider

Patient Eligibility.

  • Medicare beneficiary

  • Two or more diagnoses of a chronic nature

  • Chronic conditions expected to last at least 12 months

  • Chronic conditions place patient at significant risk of death, acute exacerbation/ decompensation or functional decline

CMS Requirements of Participating Practitioners

  • Use of EHR

  • Build a comprehensive care plan

  • Provide CCM patients with 24/7 access to care

  • Provide access to alternative means of communication

  • Provide 20 minutes of non-face-to-face time monthly

  • Ensure CCM patients have timely access to routine appointments and are scheduled with same provider for routine needs

  • Implement process for transitions in care /development and use of Continuity of Care Document

  • General supervision of care team