Medicare’s Chronic Care Management Program & Patient Benefits – Emerging Evidence

February 23, 2022

By 2015 CrossTx became one of the nation’s first closed-loop referral management and care coordination platforms to offer a suite of configured workflows, alerts, rules-driven time tracking as well as compliance reporting to ensure clinics eligible to participate in the U.S. Department of Health and Human Services Center for Medicare and Medicaid Services (CMS) Chronic Care Management could consume the cloud-based system with ease.  Since then, nearly 100 clinics around the United States use this system to not only ensure compliance with CMS’ CCM program rules but also generate substantially more revenue.  But what about the benefit to the patient? While anecdotal data exists that proactive care coordination for Medicare beneficiaries with two or more chronic conditions makes complete sense, research seems sparse in volume.  What follows is a summary of some studies centering on the CCM program since it’s onset in 2015.  Overwhelmingly positive, the net take away should drive higher CCM utilization.

It’s widely known in health care circles that about two-third of the Medicare population involves patients with at least two chronic conditions. The elderly with two or more conditions have greater needs and more pronounced risks between clinic visits. Initially CMS didn’t compensate for any care coordination visits until the beginning of the CCM program, which offers more effective care, lower costs ultimately by avoiding costly readmissions while incentivizing the clinics with a new revenue stream.

In 2017, CMS sponsored a study https://www.mathematica.org/publications/evaluation-of-the-diffusion-and-impact-of-the-chronic-care-management-ccm-services-final-report demonstrating that positive attributes of the CCM program including proactive care planning and engagement while also lowering overall public costs.  Yet due to confluence of factors this valuable program remains underutilized.  CrossTx has already discussed https://crosstx.com//state-of-cms-chronic-care-management-program-as-clinics-prepare-to-transition-to-endemic-phase-of-covid-19/  the program got off to a slow start but recent reviews evidence a recent acceleration of utilization. https://www.annfammed.org/content/18/5/455.abstract 

CCM May Improve Diabetes Outcomes

The first study CrossTx reviewed was published in Jacksonville State University’s Digital Commons. https://digitalcommons.jsu.edu/etds_nursing/48/ Authored by Adrienne Shambray in 2021, this real-world investigation tracked a clinic that recognized the need for CCM as directed to diabetic patients. Could the CCM program, with its proactive care coordination outreach reduce readmission in the hospital?

More specifically, Shambray hypothesized that proactive nurse-driven CCM could have a positive impact on patients with diabetes mellitus.  Tracking previous glycated hemoglobin (A1C) prior to the CCM program the study’s author compared the result after three months of CCM activity. Conducting a quantitative analysis, the study reported that the sample patient populations’ probability of A1C decrease equaled 61.8%. A clinically significant finding.

What about Cardiovascular Benefits?

A Cedars Sinai Medical Center Nurse Practitioner, Simran Grewal works out of the prominent Southern California-based Advanced Heart Disease clinic. Given the grave toll of heart failure (HF) on Americans—about 6.2 million people per year are diagnosed, with a forecast to hit 8.5 million by 2030 according to the author.

It’s well known in clinics caring for elderly Medicare patients with multiple comorbidities including heart disease that HF represents a major hit to overall Quality of Life as well as mortality (death).  Previous research implied that CCM programs may positively correlate with improved patient outcomes, reduced readmissions for HF patients, and lower health care costs.  

In this study the author investigated the effect of Nurse Practitioner led CCM programs on hospitalization rates in HF patients.

Published in the peer review journal Heart & Lung https://www.sciencedirect.com/science/article/abs/pii/S0147956321001333# in 2021, Grewal found that out of 29 patients in this real world analysis, “Post CCM enrollment associates with a statistically significant reduction in HF hospitalization compared to pre-enrollment (p=0.0007; 95% Cl).  While 14 (48) of the patients with available KCCQ scores revealed no statistical delta between pre to post-enrolment, the study found that among 25 (86.2%) patients with documented LVEF (Left Ventricular Ejection Fraction) https://my.clevelandclinic.org/health/articles/16950-ejection-fraction#:~:text=Left%20ventricular%20ejection%20fraction%20(LVEF,pumping%20chamber)%20with%20each%20contraction scores, the author found 48% showed improved LVEFs after enrollment in the CCM program (p=0.20). The author concluded that “These results indicated that enrollment in a CCM program for HF may significantly reduce hospitalizations and in turn may have a positive impact on QOL with improvement in LVEF.”

What’s the Patient Point of View?

CrossTx research yields the reality that the CCM program remains markedly underutilized. Why is this the case? From the patient’s perception?  A group of consultants from Insight Policy Research and Mathematica Policy Research set up a study to learn more.

The study team structured an interview protocol for purposes of gathering important information from patients or their caregivers’ perceptions about the program.  They wanted to know more—for example:

  • How do patients learn about CCM services and their reported first impressions?
  • What do the patients think about the informed consent process?
  • Does supplemental insurance play a role in decision making to participate?
  • What were the reasons why patients offered consent?
  • What were some benefits should they deem the program positive (e.g., continuity of care, communications, etc.)?

Establishing a pool of subjects from a random sample of over 500 Medicare beneficiaries,  we provide a brief table summarizing the responses.


How do patients learn about CCM?

Patients learn in one of three ways: 1) majority approached CCM during an office visit with a primary care physician; 2) a small number reported receiving a letter or phone call from the practice or 3) from a care management explaining the services.  Over half have the patients who remembered these initial discussions found the interaction positive.

Patient perception of the IC process?

40% of the patients cannot recall if the provider requested their consent. Most in the survey had little to say on this topic. Clearly room or improvement.

What’s the role of supplemental insurance in any decision making process?

The study revealed most patients had no-out-of-pocket costs for CCM services due to supplemental insurance or Medicaid in states where that access covers. In the rare cases that patients must pay out-of-pocket they may revoke CCM services.  Funds tend to be tight for retirees. Yet a minority of patients that must pay do value the engagement.

Why did the patients provide consent? 

Generally, when patients provide consent, they do so for a variety of reasons such as seeing no harm in trying the service (especially if no out-of-pocket expenses involved)  CrossTx verifies patients benefits by improved continuity of care as well as more seamless connection to external providers and optimized charts for providers—providing primary provider better overall understanding of the patient..

Care Continuity & Communication with CCM practice

Generally, CCM doesn’t disrupt continuity of care. In addition to their normal primary provider visits they receive regular calls from a care manager, nurse or their usual clinician. Several patients found benefit with the team care approach.

What about timely access to care?

Generally, a positive outcome as many patients feel CCM improves timely access to care and affords faster access to a nurse or care manager who can quickly communicate with the physician or primary care provider.

What about care management & transitions?

Overall Medicare beneficiaries with chronic conditions appreciate monthly check in calls from their care coordinator and report generally positive, reinforcing communications.

What does CrossTx Support?

CrossTx provides a secure, HIPAA compliant cloud-based closed-loop referral management system that comes preconfigured, ready with all the rules, workflows, billing parameters and reporting needed to comply with CMS.  CrossTx recently reported on preventable audits that led to some clinics remitting substantial sums of money.

  • Web-based and easy to access in addition to seamless integration with the clinics electronic health record, the CrossTx platform supports the end-to-end service elements associated with CMS’s CCM program including:
  • Initiating visits
  • Documentation & data collection using compliant system
  • 24/7 access & continuity of care
  • Comprehensive care management 
  • Robust configurable care plans
  • Transitional o care management
  • Home-and community-based care coordination
  • Real time communications (including care team & patients)
  • Community/Social Determinants of Health (including connectivity to area aging agency)
  • Patient consent
  • Decision support & reporting
  • Referral management & network building (to include behavioral health, community services, etc.)
  • Other CCM modules including Behavioral Health Integrated, Remote Physiological Monitoring and Principal Care Management
  • Audit train & turnkey system management
  • Service levels
  • Seamless interface with electronic health records (e.g., Cerner, Epic, eClinicalWorks)
  • Integration with Health Information Exchanges and data lakes

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