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The Chronic Care Management (CCM) Problem…That No One Wants to Talk About

By Jon-Michial Carter, CEO-ChartSpan

Medicare’s Chronic Care Management (CCM) program is one of the most important and promising value-based care programs the Center for Medicaid and Medicare Services (CMS) has established. It’s also a program that is broken and plagued with dysfunction.

I have a pulpit to tell this story from because I am fortunate to run the largest chronic care managed services firm in the U.S. I hope any doctor, practice or health system in America thinking about offering their patients access to Medicare’s CCM program will read this first. If you don’t, failure is almost certain.

The problem? Patient churn. The other problem? Nobody considers patient churn before they start a CCM program.

The False Perception

Medicare’s Chronic Care Management program is a specific, fee-for-service program, designed to focus on Medicare patients with two or more chronic conditions. The program requires monthly telephonic or electronic check-ins with patients to ensure they are following their doctor’s care plan. Medicare wants providers to pay attention to their Medicare patients BEFORE they become high utilizers. “High utilizers” are Medicare patients admitted to the hospital or those that incur expensive procedures. Worse, they are the Medicare patients readmitted to the hospital because their conditions are not well managed.

Shallow analysis implies high utilizers are the “problem with healthcare” because of the high price tag attached to these patients. That is as thoughtful as blaming the victim for the crime. Your grandfather’s hospitalization for his recurring congestive heart failure is not the problem. Our inability to provide your grandfather with preventative care once he was diagnosed with congestive heart failure is the real problem. Data shows that if we invest a fraction of what we are paying for expensive hospitalizations into preventative care coordination, we can dramatically reduce costs and improve outcomes. Want proof?

CMS conducted a retrospective analysis of two years’ worth of claims data for patients in CCM programs. They didn’t analyze some patients; they evaluated all enrolled CCM patients, even if a patient was only in the program for a month. The results were stunning:

• For patients enrolled in the program for 12 months or less, Medicare and taxpayers saved $11.48 per patient, per month, after provider reimbursement.
• For patients enrolled in the program for more than 12 months, Medicare and taxpayers saved $30.34 per patient per month, after provider reimbursement.
• Hospitalizations, the area where we spend more money in healthcare than anywhere else, were reduced by 4.7% for patients enrolled in a CCM program.
• ED visits were reduced by 2.3% for patients enrolled in a CCM program.

I challenge you to find any value-based care program launched by CMS that has ever achieved those types of numbers. You won’t find one. There has never been a more effective program at reducing costs for Medicare patients.

CMS says 72% of all Medicare patients have two or more chronic conditions, making them eligible to enroll in a CCM program. That means that of the current 61,000,000 Medicare and Medicare Advantage patients in the country, roughly 44,000,000 are eligible for CCM. If we could enroll 100% of those patients in CCM, and keep them enrolled for more than a year, Medicare and taxpayers would save Medicare and taxpayers more than $16 billion, per year.

So why aren’t we sprinting to stand up more CCM programs for patients? We are. However, in the journey to do so, most practices and health systems are failing, miserably. Many have already failed and ditched their programs. They underestimated the most challenging part of running a CCM program; patient churn.

The Real Problem: Patient Churn

Most providers think about running a CCM program only in terms of providing the monthly clinical encounter. They often fail to think about the challenges associated with enrolling patients and the fact that patients will churn-in and churn-out of a CCM program, every day.

Enrolling patients in a CCM program is mind-numbingly difficult. 70% of all patients have a copay and have to be compelled to enroll only once they genuinely believe that the $8 copay they’ll pay every month represents a good value. When I first founded ChartSpan, I mistakenly believed there would be no better person to enroll a patient than the clinician providing the monthly care services. I was wrong. Most providers and clinicians proved to be awful at enrolling patients. Reducing clinicians to administrative solicitors made them uncomfortable. Have you ever had a doctor review your copay, deductible and administrative compliance regulations with you before he or she delivered healthcare services to you? Likely not. It’s a waste of their valuable time and, candidly, something they aren’t good at.

Successfully enrolling patients into a CCM program means you need trained Enrollment Specialists, supplied with patient demographic and claims information, that are skilled at establishing the value proposition of a well-run CCM program. CMS requires that patients must give their consent to be in a CCM program and agree to pay their monthly copay. Then, and only then, clinicians can begin to do what they do best; provide monthly clinical services.

But enrolling patients is made even more complex because of patient churn. Every day 10,000 patients churn into Medicare and 7,200 churn out. Enrolling patients in a CCM program isn’t a one-time event. Managing the churn associated with CCM enrollment is a non-stop, daily operational requirement. Failure to do so means a practice or health system will eventually churn-out all of their previously enrolled patients and their program will cease to exist. I’ve encountered hundreds of practices who have ended their programs because of the challenges associated with patient churn.

At ChartSpan it took us four years and more than $30,000,000 in spending to figure out how to successfully manage patient churn for our more than 100 CCM customers. It’s been the single most challenging part of growing and managing our company. I’m not aware of a single practice, health system, or service provider in the country that has been able to achieve positive net patient churn (NPC) in their CCM program. Some may claim to have achieved positive patient churn, but ask them to show you their audited enrollment data and you’ll likely never hear back from them.

In ChartSpan’s early days, we struggled with patient churn so badly that monthly patient churn rates were as high as (-8%). The churn rate of our largest competitor was (-8.5%) per month. Annualizing (-8%) monthly churn imputes an annual NPC of (-96%). Essentially, if you didn’t try to offset your annual churn throughout the year with new patients, your program would cease to exist after 12 months. Today, I’m happy to report that ChartSpan’s NPC has been positive for the past six months. Our NPC last month was +6.8%; an annualized NPC of +81.6%. We’ve accomplished positive NPC by learning how to effectively manage the complex operational enrollment and clinical processes associated with patient churn.

I’m aware it’s self-serving to write about this subject. However, I’ve grown tired of seeing my industry struggle; with so little attention being paid to the real problem associated with CCM programs. Until CMS digs in deeper to understand the root problem of running a CCM program and works to solve it, our industry will never flourish. And, sadly, that means we’ll never achieve a meaningful volume of success that could improve outcomes for chronically ill patients and reduce costs for Medicare and taxpayers.

If you would like to respond or make a comment, feel free to email Jon-Michial at JonMichial.Carter@ChartSpan.com.