Medicare’s Push To Improve Chronic Care Attracts Businesses, but Not Many Doctors

Yves here. I would be curious to learn how health care systems and provides in other countries handle the problem of extra needs of the elderly with chronic conditions. Of course, since most do not operate on the piecework system, these issues may not come up at all.

As the article describes below, Medicare has come up with a clever-seeming system to pay primary care physicians $62 on average for 20 minutes of care a month to oversee patients with chronic conditions. Yet even though the scheme has been around since 2015, uptake by doctors has been poor, only about 10%. The program sounds and likely is overly complex, with many provides balking at the documentation and the perceived risk of being found out of compliance with Medicare rules.

Another issue that seems apparent, even though not discussed explicitly below, is the 20 minutes of work stipulation. What if a patient needs only a 5 minute call a particular month? Does the doctor have to eat that? The time assumption seems to be a Procrustean bed. Perhaps it is more flexible in practice but the article does not make it seem so.

The article also mentions, without explaining adequately, that there are all sorts of private contractors that set themselves up to help the MDs deliver these services, but most doctors see them as taking too much of the pie.

My mother’s Medicare Advantage plan (rolled over from the HMO she had been with before she was Medicare eligible, from the UAB hospital system) did not offer any such care option. If a moderately big hospital system with a vary large outpatient clinic (which = hot and cold running nurses and admin staff) presumably can’t make this program work economically, it is not hard to see that doctors in smaller practices would be even less well situated.

The article does not give any indication as to whether this program made it easier to get certain tests at home, which was a big impediment with Medicare. I repeatedly tried to get a nurse out to do a blood draw and was stymied, even though UAB was willing to process the test if we could get the vials to her. Absolutely no organization in the area with nurses or phlebotomists on staff were willing to do that, even if we tried paying outside Medicare. The very short version of the problem is that Medicare did not allow for just a blood draw as a reason for an at-home nurse visit. And even though a blood draw by itself was therefore not a Medicare covered service and was therefore kosher for being paid outside Medicare, none of these providers would consider it. Their policy was any Medicare policy-holder had to be handled solely through Medicare, period.

Don’t get me started on physical therapists. I did with great effort get some out to see her, but the restrictions resulted in her not getting the nagging she needed to progress (it didn’t help that she was highly resistant to doing exercises on her own, even with aide and my prodding and cheerleading; she was more cowed by techs in medical scrubs wearing badges).

By Phil Galewitz, Senior Correspondent at KFF Health News, a former board member of the Association of Health Care Journalists and previously a reporter for The Palm Beach Post and a national health industry writer for The Associated Press and The Patriot-News in Harrisburg, Pennsylvania; and Holly Hacker, KFF Health News Data Editor, who was previously an investigative reporter at The Dallas Morning News. Originally published at KFF Health News

Carrie Lester looks forward to the phone call every Thursday from her doctors’ medical assistant, who asks how she’s doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and her other health issues.

Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression, fibromyalgia, and hypertension.

“Just knowing someone is going to check on me is comforting,” said Lester, 73, who lives with her dogs, Sophie and Dolly, in Independence, Kansas.

At least two-thirds of Medicare enrollees have two or more chronic health conditions, federal data shows. That makes them eligible for a federal program that, since 2015, has rewarded doctors for doing more to manage their health outside office visits.

But while early research found the service, called Chronic Care Management, reduced emergency room and in-patient hospital visits and lowered total health spending, uptake has been sluggish.

Federal data from 2019 shows just 4% of potentially eligible enrollees participated in the program, a figure that appears to have held steady through 2023, according to a Mathematica analysis. About 12,000 physicians billed Medicare under the CCM mantle in 2021, according to the latest Medicare data analyzed by KFF Health News. (The Medicare data includes doctors who have annually billed CCM at least a dozen times.)

By comparison, federal data shows about 1 million providers participate in Medicare.

Even as the strategy has largely failed to live up to its potential, thousands of physicians have boosted their annual pay by participating, and auxiliary for-profit businesses have sprung up to help doctors take advantage of the program. The federal data showed about 4,500 physicians received at least $100,000 each in CCM pay in 2021.

Through the CCM program, Medicare pays to develop a patient care plan, coordinate treatment with specialists, and regularly check in with beneficiaries. Medicare pays doctors a monthly average of $62 per patient, for 20 minutes of work with each, according to companies in the business.

Without the program, providers often have little incentive to spend time coordinating care because they can’t bill Medicare for such services.

Health policy experts say a host of factors limit participation in the program. Chief among them is that it requires both doctors and patients to opt in. Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don’t have a supplemental policy.

“This program had potential to have a big impact,” said Kenneth Thorpe, an Emory University health policy expert on chronic diseases. “But I knew it was never going to work from the start because it was put together wrong.”

He said most doctors’ offices are not set up for monitoring patients at home. “This is very time-intensive and not something physicians are used to doing or have time to do,” Thorpe said.

For patients, the CCM program is intended to expand the type of care offered in traditional, fee-for-service Medicare to match benefits that — at least in theory — they may get through Medicare Advantage, which is administered by private insurers.

But the CCM program is open to both Medicare and Medicare Advantage beneficiaries.

The program was also intended to boost pay to primary care doctors and other physicians who are paid significantly less by Medicare than specialists, said Mark Miller, a former executive director of the Medicare Payment Advisory Commission, which advises Congress. He’s currently an executive vice president of Arnold Ventures, a philanthropic organization focused on health policy. (The organization has also provided funding for KFF Health News.)

Despite the allure of extra money, some physicians have been put off by the program’s upfront costs.

“It may seem like easy money for a physician practice, but it is not,” said Namirah Jamshed, a physician at UT Southwestern Medical Center in Dallas.

Jamshed said the CCM program was cumbersome to implement because her practice was not used to documenting time spent with patients outside the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice started getting reimbursed by the program.

Only about 10% of the practice’s Medicare patients are enrolled in CCM, she said.

Jamshed said her practice has been approached by private companies looking to do the work, but the practice demurred out of concerns about sharing patients’ health information and the cost of retaining the companies. Those companies can take more than half of what Medicare pays doctors for their CCM work.

Physician Jennifer Bacani McKenney, who runs a family medicine practice in Fredonia, Kansas, with her father — where Carrie Lester is a patient — said the CCM program has worked well.

She said having a system to keep in touch with patients at least once a month has reduced their use of emergency rooms — including for some who were prone to visits for nonemergency reasons, such as running out of medication or even feeling lonely. The CCM funding enables the practice’s medical assistant to call patients regularly to check in, something it could not afford before.

For a small practice, having a staffer who can generate extra revenue makes a big difference, McKenney said.

While she estimates about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants the calls, she said.

While the program has captured interest among internists and family medicine doctors, it has also paid out hundreds of thousands of dollars to specialists, such as those in cardiology, urology, and gastroenterology, the KFF Health News analysis found. Primary care doctors are often seen as the ones who coordinate patient care, making the payments to specialists notable.

A federally funded study by Mathematica in 2017 found the CCM program saves Medicare $74 per patient per month, or $888 per patient per year — due mostly to a decreased need for hospital care.

The study quoted providers who were unhappy with attempts to outsource CCM work. “Third-party companies out there turn this into a racket,” the study cited one physician as saying, noting companies employ nurses who don’t know patients.

Nancy McCall, a Mathematica researcher who co-authored the 2017 study, said doctors are not the only resistance point. “Patients may not want to be bothered or asked if they are exercising or losing weight or watching their salt intake,” she said.

Still, some physician groups say it’s convenient to outsource the program.

UnityPoint Health, a large integrated health system based in Iowa, tried doing chronic care management on its own, but found it administratively burdensome, said Dawn Welling, the UnityPoint Clinic’s chief nursing officer.

For the past year, it has contracted with a Miami-based company, HealthSnap, to enroll patients, have its nurses make check-in calls each month, and help with billing. HealthSnap helps manage care for over 16,000 of UnityHealth’s Medicare patients — a small fraction of its Medicare patients, which includes those enrolled in Medicare Advantage.

Some doctors were anxious about sharing patient records and viewed the program as a sign they weren’t doing enough for patients, Welling said. But she said the program has been helpful, particularly to many enrollees who are isolated and need help changing their diet and other behaviors to improve health.

“These are patients who call the clinic regularly and have needs, but not always clinical needs,” Welling said.

Samson Magid, CEO of HealthSnap, said more doctors have started participating in the CCM program since Medicare increased pay in 2022 for 20 minutes of work, to $62 from $41, and added billing codes for additional time.

To help ensure patients pick up the phone, caller ID shows HealthSnap calls as coming from their doctor’s office, not from wherever the company’s nurse might be located. The company also hires nurses from different regions so they may speak with dialects similar to those of the patients they work with, Magid said.

He said some enrollees have been in the program for three years and many could stay enrolled for life — which means they can bill patients and Medicare long-term.

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    1. old ghost

      Indeed. If they can turn a $ they do come.

      The program Yves describes sounds a lot like the one I was enrolled in (I certainly don’t remember opting in to it, but I might have).

      I am old enough to have Medicare, and once a week on Thursdays I get a short automated phone call. I have COPD and the automated call asks 3 questions about how I am breathing. At the end of the call they tell me my response has been noted.

      The one time I did respond that I was having increased breathing problems, a live nurse followed up with a call. So perhaps this is a program that does work.

  1. PlutoniumKun

    In Ireland there is what is known as the ‘Fair Deal’ scheme for long term care, which essentially comes down to a financial assessment of how much the person can pay with a ‘top up’ from the State. Crucially, it includes a State claw back on the value of the persons home after death, although inevitably this has been weakened over the years. Its been a few years since I looked into it, but it seems to work quite well, although inevitably there family grumbles when it turns out that the government can take a substantial chunk of their inheritance.

    About 10 years ago i did an informal analysis with an Irish American friend who was comparing the costs of keeping her ailing parents in NJ or bringing them to Ireland (they had maintained Irish citizenship). Despite wage and construction costs being relatively similar, the annual cost in Ireland was about 40% of NJ, which I think can only be attributed to various forms of price gouging in the US (Ireland is not immune to this, but not early on the same scale).

    1. JTMcPhee

      Too bad the gummint can’t find ways to take gobbets of accumulated wealth from bloated renter families, to put a dent in “inequality,” which should be the “I” included in the “DEI” acronym.

      Oh wait, what am I saying? That would interfere with proppity rights…

  2. Adam1

    I’m not sure why the author found it notable that so many specialists were receiving payments. In my limited experience it seems that very often people with chronic conditions often end up seeing specialists routinely.

  3. EMC

    This is pretending to do health care without doing health care, for a co pay no less. A five minute phone call by an MA cannot identify, assess, or solve health care needs. They either get missed or referred to a specialist, which with adequate time and assessment by adequate level of skill might be readily solvable. Nothing indicates it might address genuine home based needs like access to blood draws, filling pill cases, chronic wound assessments, etc. No wonder most practices and patients don’t opt in. It’s just set up to siphon money.

  4. Laura in So Cal

    We had a mixed experience with support under my Mom’s Medicare Advantage thru Kaiser. As her Alzheimers progressed, we had no problem getting Kaiser to prescribe physical therapy 2X/week at home which went on for several months and which along with us doing the exercises daily, definitely extended her mobility by probably 9 months..which was huge. However, we couldn’t get at home NP visits/blood draws etc. until she was placed in a group nursing home. Then she was eligible for a special program where you could call directly to get quick service/answers to questions and they would send a nurse/np to see her every 6 months or for acute problems as needed. They would do blood draws. We had good phone support with their pharmacist as we changed medications or dosages. While our interactions with individual Dr’s, nurses, pharmacists were excellent, our interactions with “the system” were less so. It was my part-time job to keep up with it all.

    BTW, the physical therapists were all 3rd party contractors, but the nurses/np worked directly for Kaiser.

  5. KidDoc

    With shift-worker hospitalists, mega-group primary care providers, and changing small-network HMO’s, continuity of care is often lacking. It is not unusual for specialists – who personally follow a patient for decades, in and out of the hospital – to end up coordinating care at various levels. Knowing the patient and history, beyond scanning the chief complaint and problem list, is particularly helpful when problems arise.

  6. CA

    November 14, 2023

    What Long-Term Care Looks Like Around the World
    Most countries spend more than the United States on care, but middle class and affluent people still bear a substantial portion of the costs.
    By Jordan Rau

    Around the world, wealthy countries are struggling to afford long-term care for rapidly aging populations. Most spend more than the United States through government funding or insurance that individuals are legally required to obtain. Some protect individuals from exhausting all their income or wealth paying for long-term care. But as in the United States, middle-class and affluent individuals in many countries can bear a substantial portion of the costs.

    The U.S. spends less as a share of G.D.P. on long-term care than most other wealthy countries…

    [ Chart ]

    Here’s how five other countries pay for long-term care…

  7. CA

    The country with the longest life-expectancy:


    Long-term care insurance is mandatory for Japanese citizens age 40 and over, while in the United States only a small portion of people voluntarily obtain coverage. Half the funding for Japan’s program comes from tax revenues and half from premiums. Older adults contribute 10 to 30 percent of the cost of services, depending on their income, and insurance picks up the rest. There is a maximum amount people have to spend from their income before the insurance covers the remainder of the cost. Workers can also take up to 93 days of paid leave to help relatives with long-term care needs. Japan assigns a care manager to each person using services; each manager oversees about 40 older adults. In 2020, Japan spent 2 percent of its gross domestic product on long-term care, 67 percent more than the United States spent that year.

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