FutureFocus March 14, 2018 - Quality Data And Discharge Planning: Changes Ahead

Lisa Remington

In this week’s FutureFocus, we provide insights into how quality data influences discharge planning. Ongoing discussions at MedPAC are evaluating current discharge planning procedures and the future of the IMPACT Act for PAC providers. In another article, we focus on  Medicare reimbursement changing for physicians and new opportunities for post-acute providers to integrate chronic care management solutions. We provide resources and insights to tackle the topic. In the news, is talk about social determinants and the responsibility of providers. Learn how health systems, ACOs and payors are looking at different solutions.

Lisa Remington, President, Remington Health Strategy Group

In January 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a separately billable non-face-to-face Chronic Care Management (CCM) service to improve Medicare beneficiaries’ access to CCM in primary care. Learn insights and opportunities.

The Goals of CCM

CCM aims to reduce rate of functional decline and improve health. It includes services :

  • to enhance continuity of care,
  • coordination across providers, and
  • development of comprehensive care plans.

CCM supports beneficiaries with two or more chronic conditions by providing new “in-between visit” revenue to participating providers, stimulating practices to enhance their focus on goal-directed, person-centered care planning, and to provide “aging-in-place” resources such as proactive care management.

"Eligible professional may supervise his or her own staff, such as a registered nurse, or contract with a third party to provide CCM services."

Under the CCM payment policy, eligible professionals may bill for care management that is furnished outside office visits to fee-for-service (FFS) Medicare beneficiaries with two or more chronic conditions. The health care professional must provide at least 20 minutes of clinical staff time for CCM services in a given month (CMS-1612-FC 2014). Alternatively, an eligible professional may supervise his or her own staff, such as a registered nurse, or contract with a third party to provide CCM services.

Under CCM payment policy, independent eligible professionals are allowed to bill a Medicare beneficiary only once a month for CCM services when supervising their own staff or contracting with a third party. In contrast, hospital outpatient departments may bill a Medicare beneficiary twice for the supervision and provision of CCM services for employed eligible professionals supervising hospital staff or service providers under contract to a hospital.

These services include ensuring that each patient has a designated clinician; developing and revising a plan of care in collaboration with the beneficiary; communicating with other health professionals, including hospitalists, specialists, and other providers; and managing medication. Practices must also have a certified electronic health record and ensure that the care plan is available electronically at all times to anyone providing CCM services. Medicare beneficiaries need to consent to receive CCM services and are generally responsible for the 20- percent coinsurance for the service.


Historically, physicians have not been compensated separately for these types of activities when performed outside a face-to-face office visit. Primary care clinicians have long argued that visit-based payment undervalues the work they and their teams do for patients between visits (Press 2014). Furthermore, a growing percentage of primary care physicians (PCPs) experience burnout (Shanafelt et al. 2012), and they lack support to help patients.

The study conducted by Mathematica indicates that per-beneficiary spending for consumers receiving chronic care management services in the first six months of 2015 were $1,395 compared with $1,192 for those who received services in the first six months of 2016. 

Over the second year of the experiment, the CMS paid roughly $52 million in CCM fees and generated a net savings of $36 million, largely because those beneficiaries were less reliant on both inpatient and outpatient care.

In 2017, CMS launched a national campaign to promote CCM services. More than 684,000 beneficiaries received CCM services during the first two years of the new payment policy. 

New Opportunities for PAC Providers to Clinically Integrate with Physician Practices

For home health, hospice, palliative care, in-home services, and community-based organizations, this change provides new opportunities to bring solutions to physicians in chronic care management (CCM), patient care management and alignment of ACO quality measures.

Resources to Learn More About Chronic Care Management (CCM) and Physician and PAC Integration

*Principals, Clinical Integration and Integration of CCM, MARA and Value-Based Care

*22 Key Facts About Physician CCM Billing

*Healthcare's Next Strategic Move: MACRA

*Physicians Can Use Telehealth for Chronic Care Management in 2018

By: Lisa Remington, President, Remington Health Strategy Group and Publisher, The Remington Report