Want to Succeed at Value-Based Care? Launch a Chronic Care Management Program

June 21, 2021 /

Value-based care at ChartSpan

The Shift to Value-Based Care

The past fifteen years have proven a slower shift towards value-based care than what most have hoped. Even though the concept was introduced in 2006, there are still healthcare organizations and practices that struggle to make well-care a priority because sick-care is consuming all their time and resources. This is largely due to the way the healthcare system is designed – reactionary vs preventive. Many providers and practices are already overwhelmed, so it can be difficult to fit additional, preventative medical care into their schedules with a revolving door of sick patients. 

Despite the best of intentions to execute value-based care initiatives, overwhelmed practices can quickly watch their value-based care efforts move to the back of the priority list or become ineffective. Thankfully, the Centers of Medicare and Medicaid Services (CMS) have designed special programs that encourage practices to improve their quality of care, without an overwhelming operational burden. One of these programs is Chronic Care Management (CCM), which CMS began reimbursing for in 2015. CCM offers a substantial revenue benefit since providers are reimbursed for each enrolled CCM patient, per month. Providers will earn hundreds of dollars per year, per each enrolled CCM beneficiary with Fee-For-Service and Shared Savings, combined. Exploring CMS’ value-based programs, like CCM, can provide practices with a structured way to provide value-based care that ultimately improves patient outcomes while also providing a supportive revenue stream.

Chronic Care Management, a Value-Based Program

Chronic Care Management was designed to provide remote care to Medicare beneficiaries who have two or more chronic conditions. Since the care is provided remotely under general supervision, providers are able to partner with a third party company that specializes in running CCM programs. In fact, programs like CCM are typically the most beneficial to practices when they partner because it removes the burden of having to use practices’ limited time and labor resources, yet still provides needed, additional care to patients without interrupting practice workflow. 

In a CCM program, healthcare professionals work to close the gap between enrolled CCM patients and their providers. This includes proactively reaching out to gather health information and assist with any patient needs like refilling prescriptions, setting appointments, and requesting health records. Every month, the care team, composed of certified clinicians, will work on a comprehensive care plan for each patient that includes all patient information and is stored in the electronic health record (EHR). The care team works with the patients’ healthcare providers to set healthcare goals, follow-up on them each month, and document any changes in the care plan. This is beneficial to the provider as it often affects quality improvement efforts as well. All decision-making is still done by the provider, but the CCM team acts as an additional resource that helps close any gaps in care.

Changing Outcomes

While some providers may be hesitant to trust a program that provides patient care remotely, Chronic Care Management as a value-based program has been proven to improve patient outcomes. Studies have shown that patients enrolled in a CCM program showed reduced hospitalizations by nearly 5%, reduced emergency department visits by 2.3%, and increased preventative care E&M encounters by 8%. This extra level of care is also expected to reduce hospital readmission rates since patients are able to better manage their chronic conditions and have the support to avoid decline. These numbers can make a huge difference in the healthcare system as the aging population continues to grow. 

Better patient outcomes also make a substantial impact on costs. Taxpayers save $74 (gross) and $30 (net), per patient, per month when patients are enrolled in CCM for at least a year. Patients can also expect to see lower costs out-of-pocket since they are avoiding hospital readmissions and ED visits, as well as getting guidance on where to find cheaper prescriptions.

Patient Satisfaction

Providing better quality of care does not stop at improving patient outcomes and lowering costs. It requires the patients to actually be happy about the additional care they are getting. Patient satisfaction is a critical part of any healthcare program, but can be especially important in a program like Chronic Care Management, since the patient is required to pay a small copay to be in the program. CCM can help patients feel more connected to their providers and encourage patient engagement. A better patient experience can prevent patient turnover and overall better care. It’s important to track patient satisfaction as a metric for your Chronic Care Management program because if patients are unhappy, they will leave the program, leaving their change of improving health outcomes in the dust.




Related Articles

evolution of CCM

The Evolution of Chronic Care Management

In the United States, around 60% of adults have one chronic condition and around 40% have two or more chronic conditions. The treatment…

Read More →
CCM technology

Access to Care and Chronic Care Management

According to the Center for Disease Control (CDC), six out of 10 Americans have a chronic illness. Four out of every 10…

Read More →
IHA Partnership

ChartSpan Announces Partnership with Iowa Hospital Association

(Greenville, South Carolina) – April 26 – ChartSpan, the leading provider of managed chronic care management (CCM) in the U.S.,…

Read More →
Chronic Care Management for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

Why RHCs and FQHCs Should Care About Chronic Care Management

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) face difficult challenges in serving a unique patient population. Located…

Read More →

ChartSpan Names Christine Hawkins Chief Executive Officer

ChartSpan, the largest provider of managed Chronic Care Management programs in the U.S, announced the promotion of Christine Hawkins, former…

Read More →
Solve the burden of enrolling patients with the ChartSpan Remote Patient Monitoring Program

The Solution to Remote Patient Monitoring’s Fatal Flaw That All Providers Should Know About

You may have read our 2020 blog on the challenges of Medicare’s remote patient monitoring program. Since the article was…

Read More →

ChartSpan to Solve Low Remote Patient Monitoring (RPM) Participation with Launch of the First-Ever RPM Enrollment-as-a-Service

ChartSpan to Solve Low Remote Patient Monitoring (RPM) Participation with Launch of the First-Ever RPM Enrollment-as-a-Service ChartSpan is excited to…

Read More →
Kansas Partnership

Kansas Health Services Corporation Partners with Top Chronic Care Management Provider, ChartSpan

Kansas Health Services Corporation (KHSC), a for-profit subsidiary of Kansas Hospital Association (KHA), has announced they have selected ChartSpan as…

Read More →

Subscribe for News

Complete the form below.

This field is for validation purposes and should be left unchanged.


Visit the Research & Education Library

Best practices, videos, case studies and more.