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CMS changes will bridge old and new models of chronic care management

New approach can mean substantial revenue increases for health care providers

The prevalence of chronic conditions presents one of the greatest risks to the U.S in terms of population health and well-being. However, many serious conditions such as hypertension or hyperlipidemia can be successfully managed if the patient follows a clearly documented treatment plan. To that end, changes to the chronic care management model by the Centers for Medicare and Medicaid Services (CMS) offers an out-of-the-box approach to improve the outcomes for patients with two or more chronic conditions.

Medical practitioners can bill non-face-to-face communications with Medicare beneficiaries, reducing the need for costly direct evaluations when a simple instruction may be all that is needed.

Recent analysis from consulting firm Frost & Sullivan finds that despite a list of cons, the potential merits of this program demonstrate value. Even though it falls short of the new payment taxonomy and true telehealth, this approach to chronic care management is a transitional phase, beginning in the old world of Medicare while possessing the potential to evolve with changing demands.

“The new reimbursement program provides a user-friendly and information-based treatment plan, allowing patients to access expert advice for treatment-related questions each month,” says Frost & Sullivan Healthcare Industry Principal Victor Camlek. “This may have a measurable impact on the elimination of unnecessary hospital readmissions and in-person visits.”

Although this promising revenue-generating system involves a minimum of 20 minutes of non-face-to-face service, the actual cost of delivery is difficult to project. The lack of full clarity regarding requirements could render the service as unappealing from an economic perspective. The need to get patient consent for a non-face-to-face service that will necessitate copayment, could further delay transitions to the new model.

Healthcare practitioners must comprehend the full implications of assuming this role, and carefully analyze the total cost of service on a practice-by-practice basis. Perhaps the most important factor to recognize is that this service can only be billed by one practice per month. That practice will assume full care-coordination responsibility, including the use of certified electronic health records needed when communication is necessary between medical experts.

“The success of the service among Medicare beneficiaries may stimulate a wider adoption by other payers,” says Camlek. “If this model lives up to its potential, private payers and benefit plan managers may wish to establish similar coverage over time to cut down on non-essential medical interactions, improving the patient’s quality of life in the long run.”


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