1. Sustainability of Care Management Services
Timothy P. McNeill, RN, MPH
Healthcare Consultant

2. Care Mgmt and Health Reform1
Care Management Svcs 2
Implementation / Risk Strat. 3
Next Steps 4

3. New Business Opportunities Abound
The shift towards financial incentives that align with preventing costs has created new business opportunities
MACRA
Merit Incentive Payment System (MIPS)
Alternative Payment Models (APMS)
Medicaid Reform
1115 Waiver
Health Homes
Population Health
Identification of populations that are most at-risk for increasing costs

4. Support for Physicians to Expand Utilization of CCM
Option to outsource services to a third party care management company with expertise in working with target populations
Patient contact and care management is expected to be non-face-to-face
Add-on code for reviewing the person-centered plan
Services can be provided by “Clinical Staff” as compared to administrative staff
Clinical staff can be leased employees, contractors, or employees of a third party care management company

5. Evaluation of Risk-Based Contracting: Evaluation of Bundled Payment Programs
Publicly available market research
CMS Bundled Payment for Care Improvement (BPCI) Initiative Models 2 – 4: Year 2 Evaluation & Monitoring Annual Report
Released August 2016
Available for download:

6. Key Takeaways from Evaluation Report
130 participating hospitals
60,000 episodes of care
Primary episode major joint replacement of the lower extremity
Congestive Heart Failure
COPD
Pneumonia
Largest savings occurred in joint replacement episodes
$864 (3%) reduction in total episode costs
Few achieved savings for cardiac care models

7. Challenges for Identified in the Evaluation Report
Success requires a targeted strategy to reduce OR eliminate Institutional Post-Acute Care
Almost all savings attributed to reducing institutional PAC
Care Management is essential to success
Care management must extend into the community for the full range of the risk period – up to 90 days
Managing patient expectations related to PAC use
Challenges with establishing relationships with PAC providers

8. Care Management Services

9. Medicare Part B: Care Management Coverage
Transitional Care Management (TCM)
30-Day intervention to coordinate care after an acute hospitalization or institutional placement
Chronic Care Management (CCM)
20-Min care coordination intervention with low-complexity
Complex Chronic Care Management
60-Min Moderate – High complex care coordination
Behavioral Health Integration (BHI)
Care Coordination to address behavioral health issues, such as Depression
Ex. Collaborative Care Management (CoCM)

10. CPT/HCPCS Codes and Rates
The rates shown are the National Reimbursement Rates

11. Description of the population receiving CCM today
513,000 Unique Medicare beneficiaries received the service
Frequency = 4 times per person
Participants tend to have a higher disease burden and suffer from social determinants of health
Recipients are more likely to be dual-eligible
Physicians report clinical staff spending 45 – 60 min per month per beneficiary on CCM

12. Key Takeaways
Primary population receiving CCM today includes dual-eligible beneficiaries (total population = 513,000)
MedPac data reports approximately 10 million dual-eligible beneficiaries nationwide
MACRA baseline performance established CY2017
Physicians can outsource CCM to a third-party care management company
Third party must provide services using U.S. based clinical staff (cannot outsource to foreign call center)

13. 2017 Physician Fee Schedule
Final Rule
Posted November 15, 2016
Regulation # CMS-1654F
Available:
Key Changes
Significant expansion in care management reimbursement
Services can be outsourced to a third-party care management company

14. Transitional Care Management

15. Medicare Part B beneficiary
Eligibility for Transitional Care Management & Chronic care management services
Medicare Part B beneficiary
Medicare Only
Dual Eligible
TCM – Admission to an Acute Care Facility, SNF or mental health facility
CCM – Two or more chronic conditions and risk of deterioration in health status if conditions are not managed well
Applies to Non-CPC+ Practices
CPC+ Practices benefit from expanded care mgmt reimbursement

16. Transitional Care Management (TCM)
TCM provides reimbursement when a thirty (30) day care transition service is provided to a Medicare beneficiary that is admitted to one of the following:
Acute Care Facility
Mental Health Institution
Skilled Nursing Facility / Subacute Rehab facility
TCM services can be a qualifying service for Chronic Care Management or BHI services
Specific time points must be met to submit for reimbursement.

17. Transitional Care Management (TCM) key timepoints
48 hours of discharge
Make contact with each enrolled beneficiary
Determine potential risk
Med review
Coordinate homecare / Discuss needs with caregiver
Day 7 / Day 14
Conduct a face-to-face encounter
Complete medication reconciliation
Review history / make referrals / screen for psychosocial risk factors
Day 7 – 30
Update transition plan / address identified issues

18. Transitional Care Management (TCM) Barriers to Implementation
Missed requirements
Lack of awareness of hospitalization / discharge date
Electronic notification of transition data
Day 7 / Day 14 follow-up appt coordination
Support to address behavioral health issues impacting health outcomes
Depression co-morbidity with chronic disease
Support to address social determinants of health

19. Transitional Care Management (TCM) Best Practices
Define a dedicated team to coordinate care transitions services
Team should be multi-disciplinary in nature
Ability to Address Social Determinants
Access to community resources
Ability to navigate the State Waiver / LTSS system
Ability to address psychosocial factors
Partner with Essential Community Resources
Community-Based Organizations with history of addressing high-risk populations
Aging Disability Resource Center (ADRC)
Area Agencies on Aging
Centers for Independent Living

20. TCM link to CCM TCM link to CoCM/BHI
Transitional Care Management (TCM) Integration with other Care Management Services
TCM link to CCM
Assess for need for ongoing Chronic Care Management Services
Obtain consent for CCM
Develop expanded CCM person-centered plan
TCM link to CoCM/BHI
Assess for need for ongoing behavioral health care management
Refer to behavioral health care management team
Develop behavioral health care management plan
Consider evidence-based program intervention
i.e., PEARLS for Depression management
Complete Assessment

21. Chronic Care Management

22. Required Elements - Consent
Must obtain beneficiary consent prior to initiating services
Verbal Consent is acceptable
Must document in the record that verbal consent was obtained
Consent process must include educating the beneficiary on Part B cost sharing requirements
Medigap plans cover cost-sharing requirements
Dual Eligible beneficiaries have Medicaid as their Medigap policy which cover the Part B co-insurance requirement

23. Required Elements – Person-Centered Plan
Plan should address Medical, Social, and Psychosocial factors impacting health
Identify interventions to address each area of need
Services are intended to cover up to 12 months
Update plan as needed during the duration of the intervention

24. Creating a Care Plan Support the completion of a person-centered plan
Services that can be included as part of the Care Management Person-Centered Plan
Education and outreach
Disease Self-Management Support Services / Classes
Care Coordination
Communication with all providers
Support to address Psycho-Social Barriers impacting health
Medication Reconciliation
Health Coaching services

25. Behavioral Health Integration

26. Behavioral Health Integration (BHI) / Collaborative Care Management (CoCM)
Care Coordination for persons with a behavioral health diagnosis
This service can be provided by a third party care management company
Services can be reimbursed for the same beneficiary receiving CCM as well as CPC+ Practice sites – during the same month
BHI services
Outreach and engagement
Initial assessment/person-centered planning
Development of patient registries
Patient activation and health system navigation

27. Collaborative Care Management (CoCM) Requirements
CPT Codes: , 99493, and 99494
Reimbursed under Medicare beginning January 1, 2017
Primary care billing codes
These codes reimburse for coordination of care and support for the patient with a behavioral health diagnosis.
This is not reimbursement for treatment or therapy
This is reimbursement for behavioral health care coordination and support provided by primary care
Treatment, therapy, and primary care E/M continue to be reimbursed – separately
Services are not appropriate for psychiatry

28. Collaborative Care Management (CoCM) Staff Req.
Treating Practitioner
Typically the Primary Care Provider
Physician or Non-Physician Provider (NP, PA, CNM)
Behavioral Health Care Manager
Individual with training in behavioral health, working under general supervision of the billing practitioner
Psychiatric Consultant
A medical professional trained in psychiatry and qualified to prescribe the full range of medications

29. Behavioral Health Care-Manager
No minimum license req.
Assessments
Administer rating scales i.e., PHQ-9
Provide face-to-face or non-face-to-face services to support the beneficiary
Billed on a calendar month
Billing based on an aggregate of time over the calendar month (60 min)
Ability to engage the beneficiary outside of clinic hours or the clinic location
Coordinate between primary care and behavioral health team

30. Risk Stratification Strategy

31. CMS Medicare Chartbook:

32. Nearly 70% of FFS Medicare has 2 or more chronic conditions

33. Per Capita Expenditures increase as the conditions increase

34. CMS Analysis: Social Determinants of Medicare Advantage Plan Performance

35. CMS Analysis: Social Determinants of Medicare Advantage Plan Performance

36. Concerns about access to CCM & CoCM
MACRA mandates that CMS track access and utilization for chronic care management for high-risk groups including the following:
Racial and ethnic minorities
Rural Populations
Dual Eligible Beneficiaries
Expanded HCBS Services

37. Risk Stratification Strategy: Multiple Chronic Conditions
Persons with multiple chronic conditions can benefit from care coordination programs that include:
Health Coaching
Disease Self-Management Education
Patient Activation
Support to improve
Medication Adherence
HCBS

38. Risk Stratification Strategy: Social Determinants of Health
Low-Income Status has been proven to have a negative impact on achieving defined clinical outcome goals
Populations impacted by social determinants of health need support to address social and psychosocial factors impacting health outcomes
Successful interventions extend beyond the clinical setting and into the community

39. Risk Stratification Strategy: Behavioral Health Co-Morbidity
Multiple studies have shown that the presence of depression and social isolation correlate with significantly higher costs and poor clinical outcomes for persons with heart disease such as congestive heart failure.
Depression in the older adult population is particularly difficult to identify and manage

40. Where Do We Start Determine how our teams achieve clinical integration
Determine the best option for referral management and outcome reporting of clinical measures
Establish mutually agreed upon program goals that align with value-based payment contract requirements
Define how we will track ROI
Data tracking
Outcome measurement
Continually report on ROI analysis whenever possible

41. Pilot the Process
Identify One Provider within the organization to test the process
Seek out a champion
Develop a model of sharing clinical data
Establish a process of targeting the participants
CBO and Provider gain knowledge of the culture of the business
Embed a health coach within the practice

42. Questions