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Chronic Care Management Done Right

Posted by The CareSync Team

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Aug 15, 2016 8:30:00 AM

Chronic care management and value-based care - bright ideas

Recently, VP of Client Solutions for CareSync™, Mark Nalywajko, spoke with Dr. Scott Maron, a board certified internist, to get his insights into Chronic Care Management (CCM) and his experience using CareSync’s CCM services since January 2015. Dr. Maron was an early and highly influential adopter of CCM and CareSync’s second CCM client.

In this post, Mark and Dr. Maron discuss some of the barriers physicians face when trying to implement CCM on their own and what care coordination can mean for a practice and its patients.

Dr. Maron is a valued CareSync client and has been an integral part of our growth over the last year and a half. He has been a board certified internist since 1995, practicing in northern New Jersey. He is also a Medical Director of Optimus Healthcare Partners, the most successful ACO in New Jersey, and has served as the Chairman of the Quality Assurance Committee at Saint Barnabas Medical Center for over 10 years. His practice, which has three physicians and two nurse practitioners, has been using CareSync since January 2015 for chronic care management. Dr. Maron brings outstanding perspective to not only CCM as a whole, but his experience with CareSync.


Mark: Dr. Maron, would you share why you’re passionate about CCM and why you feel its implementation is a big part of the shift from fee-for-service to value-based care?

Dr. Maron: Optimizing quality of care in my own practice, as well as in the hospital, has been something I’ve valued my entire career. However, delivering the best care often requires having established processes as well as resources that, as a practicing physician, I didn’t always have available to me.

Now, chronic care management gives me those resources. For me, CCM makes it possible to deliver the type of care I’ve always wanted to provide.

Clearly, providing that type of care has also become increasingly important to CMS, and for good reason.

As we all know, the United States spends more than most countries on healthcare, but our outcomes have not been as impressive as we would hope. The fee-for-service model rewards physicians for doing more, but not for doing better. So Medicare believes, and I strongly agree, that if we reward results of healthcare, doctors will change their practices to deliver higher quality, more efficient care.

CareSync is the clear choice for implementing CCM in your practiceCare coordination has been on Medicare’s radar for quite some time. The move toward coordinated care started with electronic medical records in an effort to make records more standardized and population management possible. Then we had Accountable Care Organizations (ACOs), an initiative to reward doctors for delivering higher quality. This was followed by transitional care management codes, which were created to encourage communication between inpatient and outpatient care. And, most recently, Medicare offered the chronic care management code, CPT Code 99490.

Mark: What do you see as some of the barriers to practices implementing CCM on their own?

Dr. Maron: What I have seen personally is that doctors have not been using chronic care management as much as Medicare hoped. Perhaps it’s from fear of not knowing how to implement it.

My understanding is we’ve been seeing more large organizations adopting CCM as a way to help their patients. This isn’t surprising because they have the resources to try something new. But for smaller offices, it’s hard to create a new workflow or new process. It takes time to get the hang of it and I think that’s a barrier for many doctors to join the CCM bandwagon.

Then there are the requirements. Even the larger organizations have found that to be a challenge and are now switching to outsourcing.

You need to explain the program (this is a Medicare sponsored program, you may be responsible for a copay, only one provider per month is allowed to deliver or bill for this service, you’re allowed to revoke the service at any time, this is how to cancel) and get the beneficiary’s written consent.

You must spend a minimum of 20 non face-to-face minutes working with the patient's chart. You can talk to the patient on the phone, obtain records, or consolidate records into a comprehensive care plan, but you must spend at least 20 documented minutes of non face-to-face coordinated care.

You have to provide medication reconciliation, oversee and track medication adherence, and manage transitional care. In other words, getting in touch with the patient within a few days of discharge from an acute facility or a nursing home and following up to minimize readmissions.

And you need to make the patient’s records available electronically to any caregiver, family member, physician, or healthcare provider that needs to access the records. And faxes aren’t acceptable. You must have a certified EMR to deliver this service.

Mark: As you know, CMS announced its proposed 2017 Physician Fee Schedule, which includes proposed changes regarding electronic exchange (read about the impact to CCM here). But under the current requirements, when it comes to the feasibility of a group practice generating a patient-centric care plan, inviting all community members to share it, and pushing toward interoperability, how much of a challenge do you think that presents?

Dr. Maron: That is definitely a huge challenge and, in my mind, part of the core of CCM. I think the meaningful use concept Medicare was hoping to have was intracommunication and operability between various physician groups, but what we came up with was hundreds of separate EMRs that will not talk to each other. I can’t see what’s in the cardiologist’s notes. He can’t see what medications I prescribed.

When Medicare came out with CCM, they mandated that there be a comprehensive document that’s accessible to everybody regardless of their particular EMR. So to deliver CCM, you must have some way to have an electronic medical record that anybody can see. In my EMR, for example, we have a patient portal. That’s great for my patients because they can use it. But other physicians cannot access it, so it does not comply with CCM. That is a significant barrier.

Mark: In light of these challenges, I’d like to get your thoughts on a buy versus build scenario and what you would advise.

Dr. Maron: When I learned of the code back in 2014, I certainly explored doing it myself and would generally have liked to do that. But I did the math and realized that I might be able to build it, but the profit wasn’t going to be tremendous. I didn’t have the time to create the processes and make sure that I was following all of the recommendations and supervise it. I was busy taking care of patients and doing other things. Implementing CCM was a full-time job that I was not really ready to do.

Then I thought, “Okay, I’ll hire somebody to do that for me.” But nobody knew how to do CCM because the code didn’t even come into existence until 2015. Even now, unless someone has actually been doing it somewhere else effectively, it’s very hard to find somebody who would know how to properly implement CCM.

CCM done right involves univeral availability of a Care PlanI’ve also seen a number of EMRs and the vendors have been trying to create modules to deliver CCM. You can create a care plan type of note, which is basically very similar to the annual wellness visit. But it’s really the universal availability of that care plan that’s missing. Seeing it in your personal EMR, in your patient portal, is not good enough. And that’s really the main obstacle about doing it internally with your own EMR.

Finally, I’m the medical director of our ACO, and I go to different practices and talk to them about chronic care management. A number of them have tried to do it on their own, and none of them have succeeded because it’s an overwhelming process to try to build it from scratch. I found that outsourcing it to CareSync, which presented me with a turnkey approach, was simplest and allowed me to get things moving quickly. My patients started benefitting from it immediately as opposed to a slow ramp up of me trying to do it on my own and failing and making mistakes along the way.

Mark: Obviously, we’re thrilled you chose CareSync. Would you describe the steps you took to reach that conclusion?

Dr. Maron: It was basically my task to come up with a CCM solution for all our doctors in the ACO. Optimus’ ACO is tightly bound to another ACO, Atlantic ACO. Together we have 300,000 patients, with 100,000 of them being Medicare patients. That meant we basically had 100,000 patients we needed to provide this to.

I started out by simply Googling chronic care management and came up with a dozen vendors who touted that they deliver CCM. I interviewed them and found that almost all of them, except for CareSync, had a product that they were going to adapt to deliver CCM.

One was helping with annual wellness visits, another one was a revenue cycle management company, another one was trying to do telemedicine. They all had a little niche of what they had been doing in the past and now that this code was available, they were desperately trying to figure out how to leverage it for CCM.

They all offered me low. “If you help us develop our product, we’ll give you a good rate,” was their approach.

When I went to CareSync, they were also very nice, but they were saying something completely different. They were saying, “We already do this. It’s what we’ve been doing for years and now we’re lucky enough that something we felt was valuable is something Medicare feels is valuable, too. Something we’ve been doing for years is now actually reimbursable.” So it was very fortuitous for CareSync, and it was a clear choice for me, because CareSync is the only vendor that had any experience on January 1, 2015, from day one, actually delivering CCM.

In choosing who will provide your CCM, you certainly want them to know the compliance components of the code. You want them to have the technology, as well as the ability to see how to fit it into the workflow of your office. But you also need that deep level of experience to act as a true consultant for your practice.

In CareSync’s case, they’re able to pull from the experience of installing a solution like this in 350 different offices across 33 different states. That’s certainly going to make a noticeable difference in implementation.

Mark: Would you share your experience with that implementation process and how we have managed the account since you’ve been working with us?

Dr. Maron: I work with a number of practices at the ACO, and every practice runs differently. Every practice is going to have its strengths and barriers that you might not have expected in implementing CCM or any other process. It’s really a very individualized approach.

What I’ve found with CareSync, specifically, was they were and have always been very receptive to my issues. If I had a problem, I’d have four people on the phone having a webinar or discussion to figure out how they were going to solve this problem, and the problem got solved very quickly.

Chronic care management is not one size fits allNow we’re rolling it out to all the other practices at the ACO. As each practice comes up with their own issues, CareSync puts out each fire, one by one, and adjusts as needed to personalize the product that they’re delivering to that individual office. You can’t just take CCM out of a box and give it to somebody and say, “Okay, this is going to work for everybody.” Practices are different.

With CareSync, they literally have an implementation team that can show up at an office, walk the practice through best practices, and develop a workflow that fits their needs. That’s invaluable.

Mark: Can you tell us some of the benefits your patients have experienced with CCM services from CareSync?

Dr. Maron: I’ll start by sharing something that happened just before we began this conversation. I was in the hallway and overheard a patient telling my partner how much she loved the CCM services and how much she appreciated being able to talk to someone who was so nice and who knew her so well. It was a great unsolicited endorsement of CCM and CareSync specifically.

The person who usually connects with my patients is Delores. Delores is very knowledgeable and caring. All of my patients love her. It’s wonderful knowing there’s an extra member of my patient’s care team who they’re fond of, and I’m sure Delores feels the same way.

Some physicians offices are more accessible than others after-hours so having access to a clinical health assistant 24/7 is a huge benefit for patients.

My patients also really appreciate that they have all their health information in one place and it’s always accessible whether they’re using a smartphone or not. The ones who do use a smartphone absolutely love the fact that everything is organized for them, and the ones that don’t will often have a caregiver, or a daughter or son, who appreciates the mobile access.

Additionally, we are definitely seeing fewer emergency room visits and fewer readmissions to the hospital for my patients who are using CCM. There are also times when I have not had to order a test because I can see the cardiologist ordered an echocardiogram and that information was available on the care plan. That also means the patient didn’t have to have duplicate tests.

Mark: Finally, Dr. Maron, what are some of the benefits you’ve experienced as a provider by having your patients enrolled in CCM through CareSync?

Dr. Maron: One of the most common things I see as a benefit is the medication reconciliation. If a specialist changes medications for a patient, but I don’t have that medication in my list, I need to know about it. If there’s a new medication and the patient hasn’t remembered to fill it, that’s also important to know. CareSync finds or helps me find discrepancies and resolve them. They’ve also helped us avoid errors with medications.

The fact that CCM can help prevent errors is huge, especially when you consider that a recent study from Johns Hopkins University suggests medical errors are now the third leading cause of death.

Patient access to a clinical health assistant 24-7 is a huge benefitLikewise, there’s the benefit of getting any other information through the care plan that I wouldn’t have known about otherwise. Maybe my patient has seen a cardiologist or an orthopedist since their last visit, but I haven’t had a call about that from the other physician. Maybe my patient is between office visits and they aren’t thinking about calling me with this information first. They figure they’ll just tell me about it at the next appointment.

When a patient is using CCM, you are aware of the fractured hip they had in San Diego on their vacation. You know they saw the cardiologist last week and were prescribed a new medicine. You know they’ve been admitted to the hospital unexpectedly.

Information about the between-visit health experiences your patients have is important. You might be completely unaware of these experiences unless you get a consult or your patient tells you about them during their next office visit. With chronic care management, you know about them in real time.

Implementing CCM Today Can Prepare You for MACRA Success Tomorrow

Clearly, the successful implementation of CCM adds value to the patient and the practice. But it also has far-reaching benefits as the healthcare industry continues its shift toward value-based care.

That’s because care coordination is at the core of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Merit-Based Incentive Payment System (MIPS). Providers who understand care coordination, embrace proactive between-visit care, and engage patients to become active participants in their health are in the best possible position to succeed with MACRA and MIPS.

Implementing CCM with CareSync is the perfect place to start. In fact, CareSync offers providers sufficient care coordination services to report on enough metrics in each category to fully participate in MIPS. Alternatively, CareSync can support, enhance and expand the care coordination program of a clinically integrated network to be successful with Alternative Payment Models (APMs).

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