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How Chronic Care Management Can Benefit Providers And Patients

A session led by Irina Koyfman, DNP, NP-C, RN, at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023 detailed the potential of chronic care management billing for physicians who are not currently doing it and recommendations for optimizing the process.

In the United States, more than half of all adult patients have a chronic condition, and 1 in 4 Americans have 2 or more. Coordinating adequate care for these patients can be time-consuming, and this was the reasoning behind the introduction of chronic care management (CCM) to the CMS Physician Fee Schedule in 2015.

A session led by Irina Koyfman, DNP, NP-C, RN, at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023 detailed the potential of CCM billing for physicians who are not currently doing it and recommendations for optimizing the process. Koyfman, who is the CEO of Affinity Care Expert, has been advising providers on use of CCM for years.

The main Current Procedural Terminology (CPT) code she focused on is CCM, which is billed monthly in 20-minute intervals and covers all of the care coordination activities that go along with treating complex patients with multiple chronic conditions. In 2019, she noted, CMS announced it had received positive patient and practitioner satisfaction feedback and cost savings attributed to the advent of CCM.

Still, because billing for CCM can be complicated, Koyfman noted that many physicians had stopped using it, prompting CMS to tweak the rules surrounding it, adding additional care management time beyond 20 minutes and no longer requiring a significant care plan change to bill for it.

In 2021, an additional code, Principal Care Management (PCM), was added to the roster. PCM, usually billed by specialists, can be billed for patients with 1 chronic condition and has a 60-minute-per-month minimum.

For CCM billing, patients with at least 2 chronic conditions that are expected to last at least 12 months or until the patient's death, or conditions that place the patient at a significant risk of death, acute exacerbation, or functional decline can be included. This can include anything—from asthma to diabetes, cardiovascular disease, depression, cancer, and many more conditions that fit the requirements.

There are numerous activities that count toward the minutes billed for CCM, including forming a comprehensive care plan, care coordination, medication education and reconciliation, lab reviews, preventative care reviews, scheduling, specialist referrals, and more.

"Honestly, everything that is being done [for] the patient outside of the clinic is chronic care management," Koyfman said.

There are a set of stipulations for physicians to adhere to, starting with having an initiating visit with the patient (ie, a Comprehensive Evaluation and Management, Annual Wellness Visit, or Initial Preventative Physical Exam) during which CCM is discussed. The visit should be billed separately.

Patients must also give either verbal or written consent to be treated under CCM stipulations, and they must be informed of potential billing implications from the patient cost-sharing perspective.

Once CCM is initiated, additional patient-facing provider responsibilities include assigning a designated care team member to the patient, maintaining a certified electronic health record, and providing some sort of coverage around the clock in case patients need assistance. Physicians must also form a comprehensive care plan.

All health issues must be in the care plan, not just those the physician is billing CCM for. This can include listing problems, prognoses, measurable treatment goals, assessment of patient cognition and function, symptom management plans, interventions, medical management, care coordination, and a periodic review schedule. Recently, environmental evaluation and caregiver assessment were added.

A major limitation of CCM is that it can only be billed by one physician per month, Koyfman noted.

"It's very important if you're going to think about implementing CCM and you call the patient, you want to ask, 'Is anybody else calling you?' And they'll say, 'Oh, yeah, my cardiologist. The nurse calls every month.'" In this case, whichever provider bills first would be reimbursed, and the second provider's claims would be denied.

Another important aspect is that only physicians and non-physician practitioners, such as certified nurse midwives, clinical nurse specialists, nurse practitioners, physician assistants, rural health clinics or federally qualified health centers, and hospitals and critical access hospitals can bill for CCM. Limited license physicians and practitioners like clinical psychologists, dentists, or podiatrists, for example, cannot bill for CCM.

Still, the clinical staff managed by the provider can provide the CCM services to patients under general supervision from the billing practitioner on an incident to basis.

Certain other codes can be billed with CCM, while others cannot, Koyfman noted. Transitional care and CCM can be billed together, but CCM cannot be billed with home healthcare supervision, hospice care supervision, or certain end-stage renal disease.

When implemented consistently, CCM can have a significant financial payoff for providers. If 100 patients stay on CCM for a year, for example, this could generate about $80,000 while also improving patient satisfaction with care, Koyfman noted.

Doing care coordination in-house vs outsourcing is another question, considering the workload of managing patients. Pros of outsourcing include quick implementation, a lower price tag because, no need for additional management, no need for any new technology platforms, and the scalability of outsourced help. Still, this option offers less ability to manage the team, less work visibility, potentially less integrity, less engaged providers, and less collaboration.

For physicians outsourcing CCM, it is crucial to evaluate the clinical team, technology platforms, billing practices, and fees. A clinical team with proper licensing, bilingual staff, open lines of communication, escalation protocol for incidents that need physician attention, the attrition rate, and their management.

"Why? I met a pretty large [CCM] vendor whose manager is… a veterinary technician," Koyfman recalled, eliciting a collective gasp from the crowd. "A veterinary technician was managing nurses."

Validating software is also important, with countless options of varying quality. The software's reporting frequency and thoroughness; availability of a consent template, care plan, and clock for timing; EMR integration; and the software's capabilities in terms of tracking multiple billing tracks are things to looks at. The fees also vary substantially, Koyfman noted.

Koyfman closed with a reiteration of best practices for successful and ethical CCM implementation that benefits both patients and providers, regardless of whether CCM is outsourced or done internally.

Regular team meetings, analysis of root causes of hospitalization and readmission, regular clinical conferences, and a designated person on the internal care team to be accountable for CCM activities—whether outsources or in-practice—are all key best practices, she said.

A range of challenges still exist in the space. Patient out-of-pocket costs can vary depending on insurance plans and lead to dissatisfaction, and patient reachout and enrollment can be challenging. Some patients may also not be engaged with CCM, or may agree at first but make follow-through challenging. In the same vein, providers may not be as involved with CCM as they can or should be. Verifying patient eligibility, which varies based on what else is being billed and whether another provider has already billed for it, is not always simple.

Obesity Is A Chronic Disease. It's Why Treating It Will Be So Profitable Unless Payers Push Back

While there has been plenty of buzz about how successful patients have been in losing weight while taking a new class of obesity medications, there is a growing realization that when people stop taking these pricey drugs, the pounds can creep back on. There was a frank discussion of this on Eli Lilly's first-quarter earnings conference call on Thursday. "My expectation is many patients may try coming off the drug completely to see what happens," said Daniel Skovronsky, Lilly's chief scientific and medical officer, on the call. "Maybe some will be successful maintaining their weight, but many of them will probably experience some regression of their weight back towards baseline. And this could prompt them to come back on the drug. That's probably natural, and we can expect that." Lilly manufactures tirzepatide, which is sold under the brand name Mounjaro as a type 2 diabetes treatment. Clinical trials are underway for its use as a weight loss treatment, and the Food and Drug Administration is widely expected to approve it later this year. But when it gets the FDA's nod, the company's work won't be over. Lilly will need to change the way people — and insurers — view weight loss. "On the commercial side, as we launch into the chronic weight management market for tirzepatide, we'll be very upfront with payers and health-care professionals and consumers that this is a chronic disease and a chronic medication that needs to be adhered to long-term," said Michael Mason, who heads up Lilly's diabetes unit, on Thursday. It's the chronic nature of obesity that will make these drugs so profitable, analysts have said. Some have predicted tirzepatide will become a blockbuster with annual sales of as much as $100 billion by 2035 , by Bank of America's forecasts. But there is a growing chorus focused on who will bear the burden of these costs. If health insurance companies push back against it, the lofty sales forecasts will not materialize. Already some private insurers that cover the drug will do so only for a set period of time. It's even worse news under Medicare. The federal health insurance program for the elderly and long-term disabled is banned from covering weight loss medications, although it will fund bariatric surgery. 'It's hard to imagine' For now, both Eli Lilly and the analysts who cover the company remain optimistic. Lilly expects medications to become the standard of care for obesity, and analysts are ratcheting up their near-term sales forecasts for tirzepatide based solely on the trends seen in Lilly's first quarter with type 2 diabetes patients. "It's hard to imagine by the end of this decade, that everyone doesn't just accept that pharmacologic treatment for overweight and obesity should be the standard of care and it will save the health-care system trillions of dollars over time," CEO David Ricks told analysts. "So you know, that's our position and we need to fight for that position." To make this case, Lilly and other pharmaceutical companies in the space, including Wegovy manufacturer Novo Nordisk , are pointing to the assumption that treating obesity and overweight will reduce the occurrence of other comorbidities, producing cost savings for the system. This includes conditions like sleep apnea, heart disease and cancer, among other chronic conditions. The companies are conducting trials that hope to prove this argument but it will take some time to gather enough information to document it. Specifically, Novo and Lilly are looking at whether these drugs can prevent stroke or heart attacks in patients with diabetes. They are also monitoring the impact on sleep apnea and osteoarthritis in the knee. As research continues, there are also other variations of these drugs being studied. This class of medications are often referred to as GLP-1 drugs because they mimic incretin hormones in the body known as glucagon-like peptide-1. Wegovy uses semaglutide in a once a week injection. This same drug is also sold by Novo as the brand Ozempic for diabetes treatment. Mounjaro includes a second incretin hormone, glucose-dependent insulinotropic polypeptide, or GIP. It also is administered by injection once a week. Both companies, as well as others such as Pfizer , Amgen , and Viking , are studying other incretin combinations, including ones that could be administered orally. The current state of play Novo and Lilly have the edge. Novo was the first to win approval for weight loss, but Lilly has been shown to be slightly more effective in clinical trials . Both drugs suppress the appetite of patients and slow how quickly food passes through the gastric system. The news was pretty upbeat for Mounjaro on Thursday. "Mounjaro was the highlight of the quarter with sales coming in ahead of expectations on higher [average selling prices] and with patient access continuing to tick up," wrote JPMorgan analyst Chris Schott, in a research note. Schott expects the trend to continue in the second quarter and build further in the second half of the year. "And more broadly on the story, LLY continues to represent our favorite pick in the group as we see meaningful upside to Street estimates for Mounjaro and LLY's broader incretin portfolio over time as well as a favorable setup on the stock heading into a number of important catalysts in 2023 and early 2024," he said, referring to Lilly's next-generation incretin drugs and data on its Alzheimer's treatment, among other factors. Several firms increased their price targets for Lilly shares in the wake of this week's results. Lilly shares are up 8% year to date. That's on top of a 32% gain the stock logged in 2022. On Friday, shares set a fresh 52-week high of $404.31. Credit Suisse analyst Trung Huynh expects Lilly shares could hit $420 in the coming year, which is about 6% above where shares closed Friday. Huynh increased his target due to higher expectations for Mounjaro sales this year. Schott has a Dec. 2023 price target of $430. LLY 1Y mountain Eli Lilly shares hit a fresh 52-week high on Friday In the first quarter, Mounjaro tallied $568.5 million in sales, 8% above consensus estimates. Huynh boosted his prediction for the drug's sales this year to $3.7 billion from an prior estimate of $2.7 billion. One factor driving the drug's use is an increase in health insurers covering the drug, which can cost about $12,000 a year. As of April 1, about 60% of insurers are covering Mounjaro for type 2 diabetes, up from 40% of insurers at the end of last year. During the first quarter, Morgan Stanley analyst Terence Flynn said Mounjaro's gross-to-net improved to $243 per script from $136 per script as more insurance companies added the drug to their formularies. Still, there could be a hiccup in the Mounjaro's growth trajectory. In June, coupons that help patients cover the drug's cost will expire. With the coupon, type 2 diabetes patients have been paying just $25 a month for the drug. The expiration could force some patients to stop taking it, or slow additional patients from making the move to it from other treatments. This is why it is truly important to realize it is still very early days with this drug. 'At the precipice' "We are basically just at the precipice of this market taking off," Mizuho analyst Jared Holz said on CNBC's "The Exchange" on Friday. He noted that although investors have been talking about this for a while, the ramp up in revenue is still to come. Novo Nordisk's experience with Wegovy has been encouraging for what could happen once tirzepatide gains approval for obesity treatment. In mid-April, Credit Suisse upgraded Novo Nordisk , citing the strength it was seeing in its relaunch of Wegovy after manufacturing issues that were causing shortages of the drug were resolved. However, Holz said the current usage of these medications almost makes them "vanity" drugs. "From the numbers that you've seen, I'm not really sure that the people that are really most suited for the drugs are actually getting them," he said. Holz is among those who have expressed concerns that health insurance companies may resist adoption. "$48 billion is a monster number," Holz said, referring to an annual sales estimate that Bank of America has floated for future Mounjaro sales. "... It just seems like at some point, the payers are going to, you know, obviously be impacted." —CNBC's Michael Bloom contributed to this report.

Efforts Take Root To Beef Up Health Care Options In Underserved Rural Areas

Jacquelyn Martin / AP file (2016)

A patient has eight teeth extracted by a volunteer oral surgeon during a Remote Area Medical clinic April 29, 2016, in Smyth County, Va. The clinics provide free medical care for low-income people and those who do not have health insurance. Specializing in free dental, vision and medical care in isolated and poverty stricken communities, the group sets up mobile medical centers. 

By Grace Da Rocha (contact)

Sunday, April 30, 20232 a.M.

The sun was beginning to set when residents started lining up at the doors of Tonopah High School for Nye County's first volunteer pop-up medical clinic in the town.

Stacy Smith, CEO of the Nye Communities Coalition, could see young and old residents joining the crowd despite the medical truck not opening until 6 a.M. — about 12 hours after the line started forming.

Some of those in line hadn't seen a doctor in more than 15 years, and many had severe injuries or untreated medical conditions, Smith said.

This is a normal sight for the pop-up clinic, she said, especially in an area where access to medical care can be a challenge.

The clinic is, Smith said, "a huge benefit to us because one of our biggest issues is primary care, health care, mental health care, specialty care. And so, there are many people that are using our events as the primary care not just because of lack of insurance coverage, (but) because of lack of providers."

The partnership between the coalition and Remote Area Medical began in 2016, and Smith played an integral role in bringing the pop-up clinic to Nye County and its roughly 50,000 residents. Since then, the organization has hosted a clinic in Pahrump annually — except for 2020 because of the COVID-19 pandemic — and expanded its reach to Tonopah this pastMarch.

During the two-day clinic, volunteers from the Remote Area Medical team traveled from their base in Tennessee to set up an 18-wheeler equipped with tools to perform dental and vision exams, psychological and mental health assessments, screenings for chronic illnesses and women's care.

From getting a new pair of prescription lenses on-site to pre-screenings for cancer, the pop-up clinic has become a "life-saving event" that people will wait the entire year for, Smith said.

Best yet: It's a free service.

Medically underserved

More than 100 million Americans experience challenges accessing primary health care, according to a study conducted by the National Association of Community Health Centers. Smith said it's a problem that has plagued rural Nye County since she moved here 30 years ago.

Most of Nevada's rural counties are considered medically underserved areas — a term used for counties that lack access to primary care services, according to the U.S. Department of Health and Human Services.

Southern Nye County — as well as neighboring Esmeralda and Lincoln counties — are all classified by the Health Resources and Services Administration as medically underserved areas.

In the University of Wisconsin's annual County Health Rankings, which were released at the end of March, Nye County was ranked among the least healthy counties in Nevada in 2022. It exceeds the state average for residents with poor or fair health, poor physical health days, poor mental health days and low birth weights.

There is also a severe lack of health professionals, according to the study, with one primary care physician for every 3,430 people and one dentist per 5,350 residents.

Smith believes there are three factors at play in this shortage of health care professionals: a lack of interest in rural life, the belief that there is no pay equity in rural communities and small populations that would make it harder for providers to have a steady flow of income.

These make it harder to attract health care providers and keep them in cities, since most will eventually leave for better opportunities in metropolitan areas like Las Vegas, Smith said.

Pahrump is home to Nye County's only emergency hospital, Desert View Hospital, which provides 24-hour emergency care. Pahrump, in the southernmost tip of the county, is about 60 miles west of Las Vegas.

"Because there's not adequate primary care, a lot of people do end up at our emergency rooms and into our urgent care, but even (that) has struggled," Smith said. "Our emergency room at the hospital here ends up taking on some of the burden of medical issues that should be taken on by primary care."

But, according to Smith, there are no services for residents needing specialty care, and the lack of regular health care providers — like dentists — has been a persistent issue in the county.

Many Pahrump residents must seek specialists in Las Vegas. Other residents in areas like Tonopah will drive almost two hours across the border to Bishop, Calif., for services like dental care, said Dr. Jay Morgenstern, a professor at the UNLV School of Dental Medicine.

This can be an issue for older residents who may not be able to drive, which Smith said makes up a sizable portion of Nye County's population, or those who can't afford the trip.

Legislative fixes

In the ongoing Nevada legislative session, bills have been proposed to help with the health care shortage in rural areas. Assembly Bill 277, for example, would establish rural emergency hospitals across the state for underserved communities.

"Rural hospitals in Nevada and throughout the nation are facing a crisis," AB 277 co-sponsor Assemblyman Greg Koenig, R-Fallon, said in an Assembly Committee on Ways and Means meeting about the proposal. "In recent years, many of these facilities have been struggling to maintain their operations and meet the needs of their communities. … It is a domino effect that impacts the entire community."

The bill, which has bipartisan support, would designate rural emergency hospitals as a type of medical facility licensed in the state, authorize them to receive endorsement as a crisis stabilization center under a set of specific criteria, and require the state's Department of Health and Human Services to increase reimbursement under Medicaid for certain services provided.

Blaine Osborne of the Nevada Rural Hospitals Association said since Congress greenlighted the emergency rural hospital designation in 2020, 10 states have licensed them. If AB 277 becomes law, 13 critical access hospitals — each of which have fewer than 25 beds — will qualify for the designation in Nevada.

With AB 277, emergency rural hospitals will be allowed to close their in-patient departments to allocate more support toward other areas like their outpatient units or radiology services, according to Osborne.

"This is essentially another tool in the toolbox to keep access to care in rural communities as it gives hospitals another chance before they close to try this model," Osborne said.

Assembly Bill 120 would also help with opening the doors for medical volunteers by eliminating restrictions on the amount of time a health care volunteer would need to practice medicine professionally before donating their time.

For operations like the Remote Area Medical pop-up clinics, health care providers can only volunteer in Nevada if they have a valid professional license or certificate, are practicing the service they specialize in, are not accepting money in return and have practiced in their profession continuously for at least three years prior.

By removing the last requirement, Smith said this bill would make it easier for recent med school graduates and retired health care professionals to participate in these clinics.

"One volunteer, when they're a medical professional, can make a huge difference," Smith said. "It was just heartbreaking turning these people away that were experienced volunteers. … So that AB 120 is a big one for us."

AB 120 has already won unanimous passage in the Assembly and is being considered in the state Senate.

Smith is hopeful that the health care provider shortage in Nevada will be addressed by the state's leaders as more people grow familiar with this issue but said her team would continue to partner with Remote Area Medical, Morgenstern and local businesses in Nye County to meet the community's health care needs.

The Nye Communities Coalition is expecting to serve around 300 people at its next pop-up clinic in Pahrump in October, Smith said.

"I think that we will continue to provide this for as long as we can get the partners together and as long as there is an interest (and) a need," Smith said.

Volunteering their time

The need for health care solutions seen in Nye County is what motivates medical professionals and students in medical schools to donate their time, Smith said.

These volunteers — alongside the donated medical equipment — make it so that residents can be assessed and receive treatment on the same day. Many local businesses pitch in too, offering housing and food for the workers, Smith said.

Morgenstern organized the partnership between UNLV and the Nye County pop-up clinics when he began teaching at the university in 2018. He got involved with the Remote Area Medical team through one of his daughters, who volunteered for the organization in Tennessee while she was attending college and wanted to use this as an opportunity for student outreach at UNLV.

He took 10 students in his first year but has since added two more to the annual group.

Patrina Allen, a fourth-year dentistry student at UNLV, volunteered at the last two clinics in Tonopah and Pahrump. It was familiar territory for her as someone who volunteered at pop-up clinics in Virginia while studying dental hygiene as an undergraduate.

"It's free dental care for people who are in need, and it's just good experience for the students because we get to learn," Allen said. "(And) the patients … they're just very appreciative of what we do, so it makes us feel good."

Most of the work she did during those clinics was tooth extractions, which can be necessary when a cavity becomes too severe to repair. Many who sat in her temporary dental chair not only struggled with access to care, but money to afford it as well.

The lack of dental care that many of these patients arrived with can be dangerous, even if it seems small, and putting off treatment can be even more costly, Morgenstern said. During the two-day clinic in March, Morgenstern's team saw 200 patients and performed 289 total procedures — including extractions — that would've amounted to around $47,500 total in care costs, he said.

"The mouth is part of the body, and so, it is costing us as a society more medical care bills and more medical issues because of the fact that dental conditions do lead to further medical complications at some point," Morgenstern said.

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