Navigating the choppy waters of CCM

How speedboat primary care practices can win at Chronic Care Management

Chronic Care Management, as a concept, and as a specific Medicare billing code, “CCM”, just makes sense.

Most of the things that cause premature death, disability, and physical limitations of freedom for Americans today are chronic conditions that can be controlled and mitigated by 1. behavioral and lifestyle change, 2. carefully planned and adhered to treatment and medication regiments, and 3. social and financial navigation of complex government, insurance, and health system bureaucracies.

Chronic Care Management can do all those things and now, essentially all primary care physicians can get paid for it.

I explained why I thought more small primary care practices should start doing care management last week. I pointed out that only a small fraction of Medicare FFS accepting primary care practices have started using them, and I asked why.

I got many good reasons from many experienced people.

The most common reasons included:

1. Hard to get patients to see value of paying co-payment (usually around $8 month for most straight medicare members with no supplemental coverage).

2. Hard to adapt EMRs, workflows, and infrastructure to different care model

3. Hard to find or retrain staff to do the work

4. Physicians, staff, and patients too overwhelmed by what “we’re already doing” to add something new

5. Complexity of understanding and adhering to CCM billing and coding guidelines

Yet, reading all those reasons I can’t shake the feeling that the core answer is something I became all too familiar with in my corporate career: “It’s just too hard to turn the ship”.

Medicine is full of old, bulky, difficult to steer ships. Large slow moving hospital systems dominating care delivery in a region, outdated computer systems that we’ve been locked into for decades, and a mindset of extreme caution (often rightful in patient care decisions, but excessively extended to delivery systems decisions).

Care management, its mindset and process, is very different than the way we’ve been doing medicine for decades now. It’s longitudinal and incremental in its approach, rather than episodic and dramatic. It’s mostly on the patient and family to learn, understand, modify their behaviors, and navigate the systems of care, with the care management team guiding, coaching, and supporting. This is very different than the model we’ve become used in medicine of us as the hero-physicians doing things to people, or ordering others to do them, and the patients “complying” with our orders. That paternalistic model of medicine has been out of vogue in medical education for 40 years now, but the payments systems and structures of practice are still stuck in these dark ages. Care management is one way out of these stormy seas.

But it requires a sea-change in thinking to implement this shift (I really need to get better at these extended metaphors), which is very difficult for large and established organizations.

So, if it hard for large mega-speciality or hospital system and PE merged mega-entities to steer their ships towards the wholly new blue ocean of FFS CCM payments, then who can make the switch and do it well, by patients and providers?

Speedboats. Small, independent primary care practices might be the exact right group to utilize these codes and utilize them well, if approached properly.

I’m still learning this space myself. One of the fun things about writing a SubStack is that you all get to learn right along with me. Yet, here’s my thoughts on how a speed boat practice (a small, agile, and motivated private practice of a small group of physician-owners with full decision making power) can navigate to successfully implementing a CCM program.

These are the ways I think speedboats can out run the ships in this space:

1. Strong client-centric enrollment and engagement process. Hiring and training a friendly, helpful staff that is capable or explaining the program and its value, the active partipication it will require on the patients and their families, and helping patients get past the copay barrier ( if it affects them) by either helping them understand their various benefits plans or understand the monthly fee in context of their other needs and expenses.

2. Clear guidelines and training for care managers to be empowered to solve most issues. This again comes down to training and hiring, but also empowering. Large bureaucratic systems have a hard time trusting and empowering good people. (I would argue this is a large part of the burnout crisis among healthcare professionals today). Odd ball circumstances will arise all the time in this work (examples: a patient has a neighbor that was their primary care giver, now is hospitalized themselves, and patient needs a different way of getting to appointment). If staff do not feel empowered to tackle those situations themselves, with minimal physician intervention, it defeats the whole purpose of the program. I spoke with a physician leader, who has not been having trouble with implementing a CCM program at his large health system, note that “the care managers create more work for the providers”. You need systems and empowered care managers to avoid this.

3. Focus on a few target populations, then add more as you master those. Pick just a few common chronic disease combos (diabetes + hypertension, for example) so the recommendations, strategies, and counseling from staff can be fairly uniform and certain aspects of the program can people routine for your staff. If your team gets repeated practice specifically helping patients insulin regiments, using CGM/glucometers, counseling on diabetic diet, and foot care, rather than jumping around to other care navigation topics in a given day or week, they will become much more effective and efficient. If you are trying to do diabetes and opiates and copd and chf and on and on, the care needs differ so much between those conditions that none of the patients will truly benefit from the program. You can always add new condition combos when you’ve mastered the first few.

4. Master the DME delivery cycle!!! Getting the right Durable Medical Equipment to your patients (walkers, CPAP machines, raised toilet seats), can literally be life-saving for your patients, but the massively complex universe of getting this equipment (much more complex than the already complex delivery world of pharmaceuticals) delivered and paid for can quickly eat up all your care manager time if you are not careful. This work is the most time consuming for care managers and most frustrating for patients. If you can, outsource this. At one of my corporate roles we used Parachute Health for this. There are other companies that outsource this work in similar ways. (Not a paid advertisement. I have no association or ownership with this company. I just really liked using their product, and really hated it when I worked at places that didn’t use this service).

These are just starting points.

There is real opportunity here for patients and smaller primary care practices, struggling to survive (or launch), if we act creatively and are willing to quickly learn and change direction.

It’s time to zip through the water and leave the mega ships behind.