Chronic Care Management Offers High Reimbursement for Low Investment

Inside: Pharmacist-led chronic care management is good for patients and for business. Here’s everything pharmacists need to know. 

Around two-thirds of Medicare patients are living with two or more chronic conditions—and with those chronic conditions comes overall poorer health outcomes and higher risk of expensive hospitalizations.

To mitigate those risks, Medicare will pay physicians to manage patients’ conditions through a service called chronic care management, presenting an opportunity for pharmacist-provider collaboration. Together, pharmacists and physicians create a comprehensive care plan for eligible patients—those with two or more chronic conditions—to help maintain or improve their health. But it is also a chance for pharmacies to get more involved in clinical care.

“I think it’s a wonderful opportunity for community pharmacies and pharmacists to explore because it’s the type of service that really plays to pharmacists’ expertise,” said Anne Burns, vice president of professional affairs at the American Pharmacists Association (APhA).

Jessica Sinclair, director of education and research outcomes at Avant Pharmacy and Wellness Center said that chronic care management has become one of the pharmacy’s “bread and butter” services. Through the Avant Institute, the pharmacy trains other pharmacists how to implement services like CCM in their own pharmacies.

“We really appreciate the value chronic care management brings to patient care and how it has impacted our business, and it’s so exciting that more pharmacists are wanting to get into this space,” Sinclair said. “It really will help move the pharmacy profession forward if we have more pharmacists conducting this type of service in collaboration with providers.”

On the business side, what makes chronic care management services appealing for pharmacies is a healthy reimbursement. CMS significantly increased the reimbursement rates in 2022. In 2021, the reimbursement for 20 minutes of CCM services was $41.17, divvied up between the pharmacist and provider. In 2022, that reimbursement has jumped to $64.03. “We’re excited to see it become an even more profitable program,” Sinclair said.

Logistics of CCM

On a patient level, chronic care management services in the pharmacy typically happen in between the patient’s visits with their provider. What that entails varies. It could mean coordination of care activities, disease state management, or addressing preventive care measures. “It’s really about creating a program that is meaningful for patients and to the providers to help impact their quality measures,” Sinclair said.

Burns notes that because medication management is part of the comprehensive care plan, it is a perfect space for pharmacists to step into. “So many chronic conditions are managed by medication. If medications are used optimally by patients, that will help control their conditions,” she said.

Other things that could fall under the umbrella of CCM include connecting patients to social services that provide assistance beyond direct medical treatments, such as transportation to an appointment. “It’s a comprehensive mechanism providing dedicated attention to addressing the patient’s overall healthcare needs,” Burns said.

Chronic care management services are performed monthly, and pharmacists generally meet with patients over the phone. “It’s very flexible, which is a good thing and a bad thing, because a lot of times people can get stuck on what they should be doing for CCM every single month,” Sinclair said.

To get reimbursed by Medicare for CCM services, each patient needs to receive a minimum of 20 minutes of care split between the pharmacist and provider each month. Pharmacists are considered “clinical staff,” and they can provide part or all of the 20 minutes of care, while the billing provider is expected to perform an additional 15 minutes of work. The time spent working behind the scenes on clinical activities counts toward that number, Sinclair explained.

Benefits for patients

The patients who benefit the most from chronic care management are those who might not have the resources or knowledge to maintain their conditions on their own. CCM services are usually initiated by the billing provider, and patients must consent to receive the services. Like most Medicare services, CCM is also subject to patient cost-sharing.

“It’s really designed to give patients who often slip through the cracks the attention they need to ensure their chronic conditions are maintained—or in some cases even improved—through regular interventions with a healthcare team,” said Burns.

Sinclair notes that by providing a monthly touchpoint with a healthcare professional rather than waiting for a visit every six months, provides an opportunity for patients with complex needs to get necessary interventions earlier. “Patients really do like to know that their provider team is monitoring them more closely and helping them reach their goals,” she said. “And while there is an individual approach to care, there are some core things that we do through CCM to address the social determinants of health and help them navigate the healthcare system.”

In addition to asking questions about medications and treatment, CCM patients often seek help setting up the proper screenings and preventive services. “They might not know how to follow through on all of that on their own, or they might not know they need to,” Sinclair said. “It’s a second chance to make sure they are addressing all those preventive care measures.”

Creating a partnership

As a team-based service, chronic care management must be overseen by a physician or other CMS-qualified health care professional (QHP), such as a nurse practitioner or physician assistant. This means that independent pharmacies can’t get a program up and running without a partnership. Unfortunately, getting that first partnership off the ground can be a challenge.

“We find that one of the major barriers pharmacies report when starting their program is securing that first provider,” Sinclair said. “But after they’ve started with that first provider, they’re able to articulate what they’ve done with their program when making partnerships with other providers in the area.”

Burns recommends seeking out physicians in your area with whom you already share a large patient base. Make an appointment to speak with local physicians about CCM and explain what the pharmacy can do to monitor and manage patients.  She added, “Sometimes it takes time to get physicians to understand what the pharmacy can bring to the table and how the information will be communicated.”

Make sure to talk about the services you already offer beyond dispensing. “If you’re offering services like immunizations or MTM, let the physician know how you have leveraged these services to impact patient care,” Sinclair said. “It’s really a team effort to offer CCM programs. I would say that without someone like a pharmacist on board, a lot of practices are hesitant to implement these programs because there is so much that goes into making sure that all the requirements are met.”

If you don’t already have a system for electronic health records (EHR), getting one in place could help sell the program to physicians. “Physicians and other QHPs are required to have a certified EHR for recording patient health information and the patient’s care plan for CCM services,” Burns said. “Having an interoperable system that allows you to share information electronically with the physician makes it a lot easier to communicate about a patient’s care plan.”

Creating the contract

Once you have a provider on board, you’ll have to draw up a contract that breaks down how the program will be managed and how each party will be paid for their time. The program will be under the direction of the physician or QHP who is able to make diagnoses and assess a patient’s progress.

A detailed contract is critical because at the end of the month the provider is the party that bills Medicare for the service, not the pharmacy. After the provider is reimbursed, they pay the pharmacy according to the terms of the contract.

The terms of the contract vary based on what providers need and what pharmacies contribute. Sinclair explained that some pharmacies create a fee schedule where they get paid a set portion of the reimbursement, while others set up a productivity-based arrangement where payment changes based on what they contribute to the service. “There are a couple of different ways to do it, and there’s no one-size-fits-all solution. It really depends on the individual relationship between the pharmacy and the clinic.”

A new rule from CMS allows pharmacists and providers to bill for more time if they end up spending more than 20 minutes on CCM services for a patient. “For a while, we were in a situation where pharmacists would spend 40 minutes a month with the patient but they could only bill for 20 minutes,” Burns said, which meant the service could quickly become unprofitable. In 2022, clinical staff can bill for additional 30-minute increments at a CMS rate of $61.26.

“Obviously, you have to document it and justify why you’re spending that much time with the patient,” she added. “Oftentimes with the initial visit with the patient, the pharmacist will spend time where an add-on code can be helpful.”

Managing the program

Because chronic care management services are often provided on the phone and there’s no need to buy additional equipment, pharmacies can run a program with extremely low overhead. “From a dedicated space and equipment perspective, getting a CCM program started is generally not as onerous as some other pharmacy services,” Burns said. “It’s mainly about having the time to put a documentation system in place and pharmacists having dedicated space to conduct the telephonic service.”

“I would say that for upfront work, make sure that someone in the pharmacy is able to learn all the background information,” Sinclair said. “It does require someone who is dedicated to the program, whether that be a couple of days a week or a half a day a week dedicated to learning. They are going to have to step away from the bench and learn how to implement things, especially when it comes to the rules and regulations around medical billing to ensure they are meeting all the requirements from Medicare.”

Sinclair stresses that time management will be crucial to running a successful CCM program. “There needs to be someone to make sure we’re not wasting time. If there is 19 minutes and 30 seconds of CCM care accumulated for the month, we don’t reach that 20 minutes and it can’t be billed.”

Though there is no additional training required, both Sinclair and Burns recommend brushing up on the fundamentals of one-on-one patient care. “Familiarity with the chronic diseases patients have is very helpful to improve the management of their chronic conditions,” Sinclair said. “It doesn’t necessarily require extensive knowledge of disease state management, but when pharmacists have some experience in the management of major chronic conditions, it makes the program more effective and more valuable.”

Complex CCM

For patients who need more than 20 minutes per month to manage their multiple chronic conditions, a related service known as complex chronic care management could be an option.

Complex CCM is for when the patient’s conditions are considered unstable enough that significant changes to the care plan need to be made on a regular basis,” Burns explained. “It’s reimbursed at a higher level and has a larger required time commitment.”

In 2022, the CMS payment for 60 minutes of complex CCM is $134.29 with a payment of $70.60 for additional 30-minute increments. Like with regular CCM, that payment is divided between physician and pharmacy according to the terms of the contract.

CCM under general supervision

One of the things that makes CCM ideal for pharmacies is that while pharmacies must be under the supervision of a physician, the services don’t have to be delivered in the same location.

“For some services, Medicare requires direct supervision, which means the pharmacist needs to be in the physician’s office, but CCM has a type of supervision called ‘general supervision,’ which means the individual working under the physician doesn’t have to be in the same physical location,” Burns said.

Under general supervision, the physician or QHP has to be available to the pharmacist, but they can collaborate remotely. Sinclair said that operating under general supervision allows Avant Pharmacy to integrate its CCM services into their regular pharmacy services.

Burns says that operating a CCM program under general supervision could be a stepping-stone to other opportunities to work collaboratively with physicians. “There are several other Medicare services like behavioral health integration that are also done under general supervision,” she said.

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