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To Copay or Not to Copay

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Chronic Care Management and the Shift from Acute Care to Preventive Health

[Editor’s Note: The following article was provided by Stone Health Innovations, LLC. Stone Health is a gold sponsor of the Marshall, Parker and Weber 2016 Professional Update. More information on Stone Health Innovations is available @]

As far back as 2013, Centers for Medicare and Medicaid Services (CMS) started encouraging physicians to move toward the concept of value-based reimbursement (VBR).  VBR is founded on the concept of paying physicians to look at the holistic care of a patient. This model encourages physicians to provide services to their Medicare patients that will keep them at their healthiest by focusing on activities such as preventive health screenings and identification of risks that might put their health in jeopardy. This is a bit of a paradigm shift versus paying physicians for one-time sick visits that lead to increased use of emergency rooms and inpatient hospital admissions.

In January of 2015, CMS released a sort of precursor to VBR called the chronic care management program (CCM). The CCM program provides reimbursement to physicians so they can bill Medicare on a monthly basis for reaching out to patients with two or more chronic conditions that put the patient at risk of declining health. Physicians have extolled the value of such a program for years recognizing its value but struggled themselves to afford the additional services and staff to provide such care.  The new CCM reimbursement is the solution to the financial challenge that providers have had in providing coordinated care to their Medicare patients but still the infrastructure to provide this level of care remained the challenge to physicians as the CMS requirements for tracking and managing the program were extensive.

Stone Health Innovations is a patient health management company that created an infrastructure solution for physician practices of all sizes to provide CCM to their patients combining information technology, clinical programs and flexible staffing models to cohesively improve care to the Medicare population. The company has been partnering with physicians since May of 2015 and has seen incredible improvement in the level of preventive health screens obtained, coordination in care for their Medicare patients and a reduction in patients that have had to go to emergency rooms or inpatient hospital settings for care.  Such care would have increased their cost burden significantly and put them at risk for additional sickness from exposure to other sick patients.

The chronic care management reimbursement, however, comes with a copay of 20% (around $8.00 per month) many-times picked up by the Medicare patient’s secondary payer like Medicaid and gap insurances, AARP as one example. This copay has generated some hesitation from physicians to implement the CCM program within their practices. Physicians believe that Medicare patients will not understand why they are paying the copay. Some physicians feel uncomfortable discussing the copay with their Medicare patients while others do not see the “return on investment” of the program. This is unfortunate for the Medicare patient and their family caregivers. The value held within the CCM program is significant in its ability to help patients improve their health, reduce higher cost of care and assist them and their family caregivers to not only get the services they need readily but to help them to coordinate those services with physicians and community agencies across the entire continuum of care; which is often the biggest challenge of all.

As the U.S. healthcare system continues to move from fee-for-service to value-based reimbursement models, the goal of all stakeholders should remain patient-focused. Until CMS considers converting the CCM program to a “preventive health program” status, of which the program truly is, the 20% copay will continue in effect. However, an annual copay of $96.00 per patient should not be a barrier to better health and coordination in care. The CCM program should be readily promoted to patients and their family caregivers by their physicians and CMS alike to reduce the burden of sickness on the patient, to increase access to healthcare services, to reduce much higher copay expenses related to higher cost of care services that are realized in the absence of a proactive chronic care management program, and to reduce the burden of care coordination on family caregivers and physicians.