Ask someone to tell you what the healthcare term “value-based care” means. They’ll likely stutter and stammer with a vague, flowery definition. Stop for a second and think about it. Can you define the phrase?
Value-based care is defined and measured by dividing patient health outcomes by the cost of achieving those outcomes. Simply, it is the cost of keeping someone healthy. For too long our industry has been practicing volume-based care. The old model delivers care with no regard for measuring outcomes or the cost of those outcomes. Even now, in our nascent evolution of value-based care, claims data shows we are struggling to find effective preventative, value-based care programs that reduce costs. The average annual cost of caring for a patient has increased every year since the industry-wide inception of value-based care.
There is a basic premise behind value-based care in medicine that is really hard to execute — every value-based care initiative is wrapped around a comprehensive preventative care program.
That’s ironic. Most patients seek care not when they feel healthy, but when they feel sick. That’s reactionary, not preventative. That’s the prevalent way our healthcare delivery system works.
Everyone cites prevention as the path to achieving value in healthcare, but implementing and operationalizing preventative care services has been challenging. Patient apathy is one issue. Patients want medications and to feel better. Prevention is low on their list of concerns. The other issue is provider adoption of preventative services that generally interrupt their “sick care” duties and often reimburse at lower rates than typical sick care services.
When the Centers for Medicare & Medicaid Services (CMS) rolled out the Chronic Care Management (CCM) program in 2015, it redefined the way services could be offered to patients with chronic conditions who needed preventative care to avoid the exacerbation of their condition(s). Medicare’s program offers a monthly reimbursement to providers of Medicare beneficiaries who receive non-face-to-face clinical care. To qualify, patients must be diagnosed with two or more chronic conditions, have been seen within the past 12 months, and have Medicare Part B or C as their primary insurance.
Medicare’s CCM program provides monthly “check-ins” for patients to assist them with low-level care needs such as assistance with appointments, prescriptions, social determinants of health (SDoH), and ensuring the patient is following the care goals established by their provider. To be clear, the clinician does not replace the provider; they complement by acting as an extension of the provider.
The benefits of CCM programs extend beyond the patient. As practices struggle with financial viability during the pandemic, Medicare’s CCM program offers a new revenue stream for providers willing to focus on preventative care for their patients.
Medicare requires CCM services to be delivered at the patient’s convenience, telephonically or electronically, removing the friction associated with patients having to take time to attend a traditional appointment at the doctor’s office.
While the program is convenient and easy for patients, it can be especially difficult to launch and maintain for providers.
Components of CCM
A successful CCM program requires complete data access and normalization. There are costs associated with managing data from an EHR or practice management system. Reconciling the missing demographics or clinical data needed for patient eligibility identification is a never-ending process, as patients move in and out of the program. These data tasks are hard and represent a substantial, ongoing labor cost of running a CCM program.
One of the most challenging parts of running a CCM program is the overhead associated with enrolling patients. This includes the recurring labor and infrastructure costs to continuously enroll patients, as well as strong analytical tools that show conversion performance.
The marketing and engagement costs associated with patient education and engagement are substantial. Electronic and physical marketing campaigns are crucial to high-enrollment conversions and ongoing engagement. Welcome packets and regular patient mailings will drive up costs.
Managing the clinical team that will deliver the program includes:
- Ongoing and structured clinician training and staffing
- Labor costs for clinicians [e.g., nurses, certified nursing assistants (CNAs), medical assistants (MAs)], pharmacy techs, health coaches and nutritionists)
- 24/7 staffing for a clinical support center
- Administrative support and clinical oversight
- An analytic platform to track interventions provided, patient inbound and outbound calls, clinical resource utilization and productivity
- Methods to document and manage SDoH and barriers to care, as well as overall performance
- Medicare compliance auditing and compliance measures (e.g., ability to record and archive calls for 10 years).
The hardest part: Patient churn
Running a CCM program is about more than providing the monthly clinical encounter. There are challenges associated with enrolling patients and the fact that patients will churn in and out of a CCM program, every day.
Patient enrollment is one such challenge: In five years of CCM data evaluation, 70% of all patients have a copay and have to be compelled to enroll only once they genuinely believe that the $8 copay they’ll pay every month represents a good value.
Reviewing your copay, deductible and administrative compliance regulations while delivering healthcare services is a waste of a physician’s valuable time and, more often than not, something they aren’t good at. A successful CCM program requires someone trained as an enrollment specialist, supplied with patient demographic and claims information, who is skilled at establishing the value proposition of a well-run CCM program. CMS requires that patients must give their consent to be in a CCM program and agree to pay their monthly copay — only then can clinicians begin to provide monthly clinical services.
Every day 11,000 patients churn into Medicare and 8,000 churn out. Enrolling patients in a CCM program isn’t a one-time event. Managing the churn associated with CCM enrollment is a continuous operational requirement. Failure to do so means a practice or health system will eventually churn out all previously enrolled patients.
It can take years to figure out how to successfully manage patient churn for our CCM health system and practice customers. I’m not aware of a single practice, health system or service provider in the country that has been able to achieve positive net patient churn (NPC) in their CCM program.
In my organization’s early days, monthly patient churn rates were as bad as -8%. The churn rate of our largest competitor was -8.5% per month. Annualizing -8% monthly churn imputes an annual NPC of -96%. If you didn’t try to offset your annual churn throughout the year with new patients, your program would cease to exist after 12 months. Today, we’ve accomplished positive NPC for the past 18 months by learning how to effectively manage the complex operational enrollment and clinical processes associated with patient churn.
By educating practice administrators and providers about the inherent challenges that must be mastered in running a CCM program, perhaps more practices will be able to deliver on the preventative promise of value-based care.
- Hayes SL, et al. “High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?” The Commonwealth Fund. Aug. 29, 2016. Available from: bit.ly/39ndJKQ.