Let’s say I’m a diabetic recently diagnosed with cancer. In the last couple months, I’ve visited multiple clinics (endocrinology, radiology, nutrition, oncology, chronic wounds), plus the ER. As a Medicare beneficiary, my out-of-pocket costs are about $400 a month.
Now, my oncologist offers to enroll me in her new Chronic Care Management program. I’m told that for a small addition to my monthly co-pay, care coordination services will be performed on my behalf. These services are “non-face-to-face” – behind the scenes – so even on months when I don’t connect with my doctor, I pay the co-pay. My doctor explains that consenting to this program will enable me to connect with my care team 24/7 and help to reduce or eliminate ER visits in the future. I’ll be able to communicate with her team through secure messaging, and I can expect to receive an electronic copy of my cancer treatment plan. Sounds great.
But hold on…Aren’t those things available to me anyway? If I request a copy of my treatment plan, I assume I would get one. And while I’ve never used it, my oncology clinic has mentioned that secure messaging is available to me now. I ask my doctor again, what do I get for this extra co-pay?
Then my doctor explains that enrolling in this program at her clinic also gives me access to something new: a clinic-monitored, user-friendly mobile app. The app sends me daily texts, reminding me when it’s time to take my cancer meds and prompting me to record how I’m feeling on a day-by-day basis. Now that sounds useful.
Almost a third of the U.S. population lives with multiple chronic conditions. Even while more than 75% of all health care costs are due to chronic conditions, people with chronic conditions receive only 56% of recommended preventive health care services. Currently, two-thirds of Medicare beneficiaries with two more chronic conditions account for 93% of Medicare spending. This means that chronic care services need to be better coordinated, and caregivers need to be compensated for time spent doing this. Enter CPT Code 99490.
Beginning in January of this year, healthcare professionals can bill CMS under CPT Code 99490 for non-face-to-face care coordination services furnished to Medicare beneficiaries with 2 – or more — chronic conditions. To bill this new CPT code, at least 20 minutes of qualifying services must be performed per beneficiary per calendar month. The key elements of these services are: 1) A structured recording of patient health information, 2) 24/7 patient access to care management services, 3) Access to continuity of care with a designated member of the care team, 4) Systemic assessment of health needs and preventive services, including oversight of patient self-management of medications 5) A comprehensive electronic care plan 6) Management of care transitions, 7) Coordination with home and community-based clinical service providers and 8) Enhanced communication opportunities between patients and caregivers.
What’s great about this new CPT code is that it incentivizes practices to make financial calculations about work units and value within a new paradigm of connected care, accelerating the shift from reactive and episodic to prevention and wellness, and paving the way for the interoperability that digital health needs to finally improve outcomes. At Navigating Cancer, we offer a software solution that enables this, by identifying eligible Chronic Care Management patients and helping practices to readily meet and report billing requirements.
At the same time, we understand what ultimately underlies success in Chronic Care Management: patient engagement. Because healthcare organizations are relying currently on their existing EMR vendors to support patient engagement, the resulting tools are not optimal and uptake by patients is limited. While healthcare organizations have been largely successful in ushering in the electronic medium of the 21st century, the experience of the patient remains stuck in the age-old, in-person provider/patient encounter, now more abbreviated than ever due to the disproportionate attention bestowed by providers on their electronic interfaces. In terms of EHR uptake, the HITECH Act has yielded success. But more frequent use of EHRs has not equated to better, more efficient care.
Two-thirds of patients have smart phones and this will only increase. At their fingertips, they already have access to turn-by-turn directions, breaking news, on-the-go shopping and conversations with their friends and colleagues, anytime, anywhere. Now it is time to let these patients engage in their cancer care with the same ready-access and ease of use, through a user-friendly mobile app.
The new CPT code for Chronic Care Management is good for patients, for providers and for payers. Yet this bundle of non-face-to-face services is not exempt from cost-sharing, and beneficiaries will find themselves responsible for any deductibles and co-payments incurred, even when they do not directly experience any services performed. While some patients will understand this and readily consent, some may not see the value in paying extra for additional non-face-to-face services.
So what happens if the patient doesn’t provide his or her consent, especially since the physician is likely already performing most of the services covered in the code anyway? For those patients, practices will do well to offer a user-friendly, clinic-monitored care management mobile application. Ideally, this application will remind patients when it’s time to take their medications, and invite them to communicate how they are feeling on a daily basis. The key to successful Chronic Care Management solution is to not just enable providers to meet the new billing requirements, but to enable patients to also spend some additional non-face-to-face time every month, engaging in their own care management.