CMS’ New Year’s Resolution: Reform Medicare Chronic Care Payments

Beginning in 2015, CMS is taking on chronic care management (CCM) payment reform. The change is being made to address primary care given to Medicare beneficiaries outside of office-based visits, such as medication refills, patient communication, and care provided electronically or by phone, according to the New England Journal of Medicine (NEJM).

How It Works

As the current fee-for-service system restricts payments for primary care to office-based visits, the new system would implement a monthly $40-per-beneficiary payment (one provider per patient) for practices that care for beneficiaries with two or more chronic conditions that are expected to last at least 12 months and that pose significant risk of death, decompensation, or functional decline. In order to receive this payment, practices must use a certified electronic health record (EHR); offer 24-hour access to staff with permission to access the EHR; maintain a designated practitioner for each patient; and coordinate care through transitions to and from the hospital, specialists, or other providers.

Practices must also work with beneficiaries to create and maintain a comprehensive care plan that includes a list of health issues; medication-management instructions; and a record of involved social and community services. Further, practices must have patients’ consent to serve as their chronic care provider and obtain it on an annual basis. Practice team members must spend at least 20 minutes per month performing non-visit-based care coordination activities for each patient.

The NEJM reports that “The CCM payment’s structure and requirements are similar to those of patient-centered medical home (PCMH) initiatives, which generally offer an additional per-member-per-month sum to primary care practices for providing enhanced services.” Practices, however, do not need to be formally recognized as PCMHs in order to receive the payment.

Challenges Ahead

The new initiative involves several challenges, particularly because the exact specifications for the care plans and how they will be audited have not yet been released. These challenges include:

  • Beneficiaries will incur a 20-percent, co-insurance payment under Medicare Part B.
  • Low-income patients may not be able to afford the co-insurance payment if they do not have supplemental insurance.
  • There may be patients who refuse to pay for CCM that was previously provided for free, which could result in practices refusing to provide further care for these patients.
  • Smaller practices with limited resources may not be able to meet CMS’ requirements for receiving the extra payments and could be rendered ineligible.
  • Current EHRs have no dedicated function for care plans, and questions remain about where in the EHR such plans will reside; therefore, development will take time.
  • The new payment structure is not restricted to primary care specialties, which could cause conflicts among multiple providers in answering who among them will be the patient’s “primary physician” for purposes of CCM payments.
  • Some practices may bill for CCM with a continued focus on volume-based revenue without investing in medical-home infrastructure.