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Webcast: Earning Medicare’s New Chronic Care Management Payments – Five Steps to Take Now

Medicare’s new monthly payments for Chronic Care Management (CCM) can improve not only patient outcomes and satisfaction, but provider financial viability and competitiveness as well. In this webcast, you will learn how to estimate their potential CCM revenue, how to use technology and clinical resources to scale up CCM to reach more patients, and how to start delivering CCM benefits to patients and providers by taking five specific steps. Don’t be caught on the sidelines as others put their CCM programs in place.


Laurie: Good morning. Thanks for joining us for today's HIS talk webinar, Earning Medicare's New Chronic Care Management Payments, five easy steps to take now. It's brought to you by West Healthcare Practice. I'm Laurie from HIS talk and I'll be moderating. I've a few housekeeping items to make you aware of before we get started. Attendee phone lines have been muted to prevent background noise. You can use GoToWebinar's Questions Box on the console to submit questions to our presenter at any time. The presenters will answer your questions during Q&A at the end. Today's webinar is being recorded, so you'll receive links to the recording and a PDF version of the PowerPoint presentation in a follow-up email.

Our first speaker today will be Bob Dudzinski. Bob is executive vice president within the healthcare practice at West Corporation. Bob received his doctorate in pharmacy from the University for Nebraska Medical Center, and has extensive experience in pharmacy benefit management, home care management information systems, and related industry topics spanning over 20 years.

Joining Bob will be Collin Roberts. Collin is senior director of product integration at West Corporation where he brings over a decade of experience in Health Analytics, patient engagement, and payment integrity. Collin is responsible for product development for a number of West's Engagement Center Solutions, including those that support product care, transition care, and routine care management. With that, I'll turn it over to you, Bob.

Bob: Great. Thanks, Laurie, good morning everyone. We're very happy to be here today and really are looking forward to helping the audience better understand or add to their acumen around Medicare's new Chronic Care Management Reimbursement. And perhaps, maybe just as important, offer some suggestions on how to maybe solve some of the challenges that organizations have been experiencing in delivering on it. And I know today that we have a wide variety of sentiment about the program. Clearly, we have some positions that have been very successful and yet some have struggled to really kind of determine the value of the program in it of itself. And I know that we have varying sentiments in between. But I think what we all believe here is that there will be elements of this program that will play an important role in the future that the industry as we all kind of trudge on, skip to, run to, a value-based system. And I do believe that engaging early on to be critical in determining what processes you'll need, systems, innovations are all necessary to be successful, again, as we move to this value-based reimbursement environment.

But before we begin to jump into that, I'd like to quickly review some of the nuts and bolts of the program in it of itself. We will also look on how to calculate potential revenue impact to your practice or maybe to your position group. And the we'll really get into what we believe are the five key areas of focus as it relates to processes, to clinical resources, the available technologies needed for really delivering an effective chronic care management program. And then we'll to close up with some of the various options in the market today, that positions providers have when it comes to standing up these resources and these technologies.

So let's just jump in. Again, just to recap, to set everybody at the same level, Medicare CCM Code 99490 took effect January this year as we all know. The program pays doctors an average of about $40 per patient per month per qualifying beneficiary. The program in it of itself carries a pretty sizeable payload for primary care, as we'll see in a moment. But now, positions can be paid for the hours of non-face-to-face time they spend on behalf of their beneficiaries with two or more chronic conditions. And for some of you, this care has been provided for free for a very long time. But for many more doctors, this offer is now an opportunity to implement a new value-based care program and get paid for it if we document at least 20 minutes per month reviewing a patient's issues and answering some of the questions that they may have.

Now, there are some basic processes and systems that doctors need to have in place really in order to capture the new reimbursement. Certainly, the use of an electronic health record, patient education, and obtaining consent. But there are also, for many providers, a few high bars, challenges around the ability to administer a comprehensive plan and care. And that also involves providing 24 by 7 patient access to care plan management as well as having some of the technologies in place to enable patients to provide communications, really beyond your four walls or your setting or from the hospital in it of itself. So for many providers, these two requirements alone really oppose some insurmountable challenges.

But however, the market around chronic care management is evolving and it's responding to these challenges really a number of solutions to help providers successfully augment their operations to deliver on the necessary scale and capacity the right technologies really in a cost effective way and really deliver on the promise of chronic care management.

You know, and this does really represent a very significant financial opportunity. For this slide, let's take a look at the reimbursement opportunity in the context of a position group of about 50 doctors. For one of those Docs, the assumption here is that there are roughly 750 beneficiaries and about two-thirds of them, qualifying on Chronic Care Management for having two or more chronic conditions. Now, not all the patients who choose to participate in this CCM program, but a conservative approach here would say just about over half will. And an average per patient per month reimbursement of about 42/43 dollars, that represents a little over $135,000 for that Doc. Now of course, if you want to multiply that across the 50 position practice, the revenue potential for the group collectively, now it's in the neighborhood of about 6.7 million.

And again, I think it's also important to look beyond some of the dollars and cents when you begin to evaluate whether or not to get into the CCM game. And so what we've added is some other considerations that you may want to think about as an example, strategic alignment. Should we establish this function as part of our evolution to a value-based care? You may eventually be asked to do beyond this. This may simply be training wheels for you to move into a value-based system. What about gaps and readiness? How prepared are we from a staffing, clinical, operational and technical perspective? And then do we read, should we, can we evaluate partnerships? Do we really need to be build out all the infrastructure ourselves? Are there other ways to effectively accomplish CCM collectively?

So with that, I'm going to turn the next series of slide presentations over to Collin and he will get into really some of the more details around CCM and how we position it in the marketplace.

Collin: Right, thanks, Bob, and thanks, everyone on the phone for joining and for HIS talk for hosting us. As Bob had said, I'm going to review the five key areas that we see as being critical to a successful hosting or owning a successful Chronic Care Management or CCM program. Those are listed here on the slide and really, are in kind of chronological order with the exception of training and support, and I'll get to that at the end. But those five areas or identification or recruitment of patients, the enrollment and the education of those same patients, the ability to engage and activate throughout the term of the CCM program, and then the ability to get reimbursed. The lost one we've got on there is training and support but really, that's primarily going be a foundation that's underneath this to ensure that all parties involved are aware of their role with which they're supposed to support as it relates to participating in a CCM program.

So as I move into the first one. Identification and recruitment is obviously the first step that you're going to want to step into. If you're not able to segment or identify those patients who are dual chronic and who would qualify for this, you're really not going to have anybody to bill against. But as you look at this, there's also other factors that are in play here. Potentially taking into consideration socio and demographic analytics and considerations to ensure that the patients that you're targeting are those that would maybe adopt being participants in a program like this. Or hire doctors of maybe technology......if you're going to use technology to help support and augment some of the functions as it relates to maybe biometric journaling and things to that effect.

And then also segmenting potentially those patients that you don't want to try and recruit. There's going to be a subset of patients that are either maybe too ill or too sick to really be able to monitor outside of the clinical setting, and you don't want to put a bunch of that towards those patients to try and get them potentially even confused around this program since they wouldn't benefit from it in the long run. Next step would be once you've got them identified, is how do you make sure that they're aware and reach to those patients? You know, you can obviously do this through the portal at point of service when the patients are actually in the physical setting. But how do you get them to come in? And some of the options maybe leveraging postcards, or even automated outbound channels through voice and text and potentially even email. All of this will help you to drive to converting them into a patient, at minimum that's interested in learning more about this.

So that takes us to the next stage which is enrollment and education. According to the rules, you do have to have an E to M or a wellness visit in place with these patients in order to capture written consent. And so as you get them in, you want to do what you can to make sure that the patient is aware and comfortable with why they're coming into this visit. So education is very, very critical as it relates to this. Because there is a co-payment involved, the patient needs to feel that they're getting something out of this, some value. And so making sure that you schedule some appointment reminders to ensure that they do come in to the appointment. And maybe once they've agreed to that, reinforcing it with additional outreachs whether it'll be additional literature that you can send to them or maybe you can even email or text them a URL to a link or a video that maybe actually updates as to more of the benefits around what this program is going to entail for them.

Once you've got them in for the face-to-face visit and you've actually educated them and brought them up to speed and they've agreed to enroll, it is required that you get their written consent as a physician to do this. It's also important to note that only one physician can manage one patient and bill for this code. So it's going to be imperative that if you are in an integrated system that you've got some clearinghouse measures to be insured that two Docs aren't trying to build for the same patient.

But once you do have it, that written consent does have to be recorded electronically in the EMR and then you also have to be able to establish some set care plan goals that this patient can adhere to throughout the course of this Chronic Care Management program. These can be things like traditional care management type things. Lose weight, make sure you're taking your readings on a regular basis, reduce the salt in your diet, things to that effect. That's a key point though because those care plan goals are items that you can leverage as touch points as you start getting into the engagement and activation phase of making sure that the patients are adhering to these and providing that non-face-to-face time. And then you also have to be able provide that care plan to both the patient and their care coordination team. Whether it be a family care coordinator, or maybe if they're specialists in their network.

So now you've got them enrolled. Now what? Well, this is where really the kind of the meat of the program. This is where you establish a partnership with that patient to ensure that they are engaged throughout this entire program. Now, not all of this time needs to be spent talking and then dialogue with the patient. Some of these items can be done on your own time, not necessarily engaging the patient. But again, in order to ensure that the patient receives value, I would recommend that there would be some form of a monthly touch point with the patient at least so that they are aware that they're continually being monitored within the CCM program.

Some of the activity that you would want to look at is their progress towards those goals. What are the goals that they had established? And how are they progressing towards those ends? Do they have any upcoming appointments? And if so, how are you going to manage those appointments to make sure that they're going to adhere to those appointments? Whether it be a diabetic getting in to see their eye doctor or their A1C or things to that effect.

Medications are critical. Medication adherence. Assuring that the patients have all the right medication, they have access to them, they're picking them up and they're taking them. The bottom three are interesting ones as well. Personal assistance. There are some patients out there that have the intent to get to these appointments but maybe not the ability. So is there a means to be able to schedule a car service for them to get there? Or maybe they don't have the means to be able to pick up their medications. So personal assistance in helping them in those manners.

Continuous education and support. Again this is, again, a foundational component, making sure that the patient understands the purpose, the reasons and supporting them throughout any challenges that they may have. And then exception based intervention. The nice thing about this is, if you are successful in setting up a CCM program, it affords you the ability to establish a value-based system as Bob had referenced but it also allows you, as you're interacting with these patients, to potentially identify those critical situations that have this not been in place, they would have ended up in the ER. So you can identify those sets, those exceptions and recruit them in for a face-to-face visit and intervene before they become critical.

Some points to consider on the right-hand side, there is a need to provide 24 by 7 care access. But there's also this multimedia patient engagement components to allow you to scale this up in a manner that is effective. So again, back to the appointments or lab reminders. To ensure that you can do that through some automation technology. Biometric telemonitoring. Whether you've got remote sensors or maybe you establish an IVR to capture readings of the patient and call those in, and not actually have to talk to a care coordinator.

Self-care videos, we've talked about. Wellness surveys. Call routings so that when the phone call comes in, you can actually route them to the care coordinator that they've been working with. But I think the most important here is to ensure that when you're communicating with these patients, you're communicating with them in a channel which they choose. So if I choose to communicate or receive my reminders about my blood pressure readings, in text send me that text message. But if I'm more interested in learning more information, you want to send that to me an email. Making sure that I'm engaged throughout the channel that I want to be engaged through.

Then the big one. Get reimbursed. It's important that you document the time that you spend. Whether it's phone time, talking with a patient, or reviewing their summaries, reviewing their readings, things to that effect. It's important that you keep this. Keep track of the time spent on this. Because while it's not a component of the ruling today, if Medicare decides to audit you'll have to have that trail to ensure that you did everything that you needed to be capitalize on that 20 minutes of not face to face time. You would bill the eligible payments. And then the other option item here is also the component that the patient's going to have some responsibility. There is a 20% co-insurance. So out of a $40 amount, that's eight bucks per patient per month. You got to ensure that you drive value back to the patient, so they understand why that money is required of them. But you should also enable them the ability to make sure that they make that payment. Now sometimes it could be just rolled up into your traditional means for billing patients. But there's other options out there where you can put in potential notifications, patient's balance notifications, reminding them that they've got an outstanding balance. Maybe that transfers into an IBR where they can actually make the payment through an IBR. Or you could transfer into your billing department to ensure that they get the payment made. But this is all about setting you up for success to ensure that you continually are getting the reimbursements you need and also making sure that the patients are engaged throughout.

And finally, the fifth step is training and support. Again, this is more foundational and it's probably throughout. But it's ensuring that all of the training requirements and all of the requirements from a CCM standpoint are identified and adhered to. But also ensuring that roles and responsibilities are clearly defined. So if the doctor needs to see the patient, he or she knows exactly what they're supposed to do when they see that patient. If you've got a care coordination team, they know exactly what it is that they're supposed to be doing when they're helping manage these patients or coordinate their care. And even more so, the patient. Understanding value of the program, why they're supposed to be doing this, the benefits that they may receive because of this. And then finally billing and consent management to ensure that you're getting the right people at the right time
All of this should be done in an interactive way, role-based, accurate and relevant, and then also make sure that you track to completion. So you've got an education series out there, make sure that you track that it has it's completed if it's a web-based model or a video link that has been required to be watched. So my line before I return this back over to Bob, is really, what are the options and what are the approaches that you have as it relates to setting up and establishing this type of a program?

You know, it's the ever-growing bill vs. buy. We've actually layered in partners. You know, you do have the option to build this on your own. But in doing so, you've got make sure that you maintain and train the staff for 24 by 7 clinical purposes. You make sure that you've got the appropriate telecommunications technologies implemented to ensure that you can communicate with these patients bi-directional as well as in the channel of their choice. And then also have an ability to target and recruit the patients outside of the clinical setting. If you're going to be wholly reliant on these patients to come in, face-to-face, and educate them on that time, the ramp on this is going to be significant. Unless you've put in a targeted approach to recruit those patients and the scale on this from a revenue ramp standpoint is probably not there.

The other option though is to partner. And you've got two really options here. One, you can partner with someone to help you create a plan and a new program, which could be a completely outsourced turnkey solution. Or you could also take that turnkey solution and start learning from it and then adopting it within your own practice as it grows and matures. One other option is within an enterprise system, or a multi-doc system, this is something that you could leverage to help recruit either additional doctors or additional patients through doctors a value-added service that you can provide to this doctors once you've got a mature program in place. So there's a selling point back into the practices.

The other option is to potentially identify those partners that you maybe already have in existence and approve upon what they're bringing to the table in comparison to what they're currently bringing to the table or could bring to the table, I should say. Things like patient targeting and recruitment. Again, outbound notifications could be critical here. Clinical overflow and after-hour support. Maybe you've got some call center reps that could be appended to this and just help with the 24 by 7. Again, communication technologies and remote patient monitoring technologies are another big asset that can be leveraged in this space. And then finally, again, the training. Making sure that you've got adequate training to help train the doctors as well as the care coordination team as well as the patients to ensure that everybody understands their roles and responsibilities. So that is everything that I have. With that, I'm going to turn it back over to Bob.

Bob: Thanks, Collin. I'm going to close here with just a little bit about our organization. And I promise to make our infomercial short. West Corporation, we're publicly traded. We're really a technology-driven communication company. We're here in Omaha, Nebraska, the heartland of America. We're about 10,000 employees. And we, as a communication technology-focused company, we participate in about every industry. So we have footprints in banking, finance, transportation, public safety and certainly health care. We do a lot of healthcare. As an example, 9 of the top 10 health plans. 14 out of the top 15 health systems, and certainly a lot of pharmacies, pharma, and employers are using West communication technologies or our clinical certified clinicians. So with that, I'm going to turn the presentation back over to Laurie.

Laurie: Okay. Thanks, Collin. As a reminder to the attendees, you can use the questions box in the console to ask questions of Collin and Bob. I have several questions already. Meg wants to know from an auditing standpoint, must the time be documented in the record or can it be calculated on the back end from start/stop times in an electronic system? Or if you've established standard times for each activity, can this be used to demonstrate the 20 minutes rather than specific documentation in the record?

Bob: Quite a question. A very good question. But clearly, there will be absolutely a need to document the time associated shared with the engagement. Some people are using their own systems. Their EHRs, their EMRs, their applications that do have built-in timers. However, other organizations are simply manually recording it, literally, stopwatch and to the end. I would not suggest allocating a given task to a defined number of minutes because I think that's very difficult to validate. So again, I would look towards the first two options as satisfying the requirements for CCM.

Collin: And I think, this is Collin, one of the things that's most critical outside of all of this is to ensure that you can tie the time spent to a patient record. As long as you can tie, attribute the amount of time that you've spent to a specific patient record and designate what was done, that's probably another critical point as well.

Laurie: Okay, thanks. Beth would like to know, our practice has started providing CCM to our patients. The co-pay is the biggest hurdle we face from both patients and providers. The providers understand the benefit to the patients. But the pushback from patients is significant. Do you have suggestions for languages to use or communication strategies to overcome this barrier?

Bob: The answer to that is yes. And that is a common challenge because, again, as you can all imagine, the common question is well I thought you were doing this before? And so I think what becomes critically important is to properly educate the patient on the value of the program and what they intend to receive from this program and differentiate what you have historically done and how the system has ultimately been approved. Or improved, I should say. And yes, to this audience we can provide additional verbiage around how to overcome that particular hurdle.

Laurie: All right. Thank you. Will would like to know, a lot of this seems to be manual tasks. Are you seeing any technology vendors that are designing around the coordinated delivery of this service?

Bob: The answer is yes. And there is continued focus on delivering technology to bring scale and capacity. As an example, we touched on a couple of these in the slide. They maybe weren't very conspicuous per se. But as an example, in the recruitment process. You know, the ability to hand a data file to a vendor who can do an automated outreach to do an employment reminder or maybe even educate, do some pre-educational work to your patient population at scale. So in other words, the trick here is to get them engaged and bring them and enroll them into the program. Add to that then the ability to use additional technologies to facilitate some of the work around the engage and activate portion of our slide. Collin mentioned using, as an example, outbound active voice response technology to capture a blood pressure reading, do so decisioning on it, and then really, if that blood pressure reading is high, use communication technology to connect that patient back to the doctor's office. The consumption of remote monitoring is certainly proliferating in the marketplace.

So what we're seeing today, is leveraging communication technologies in all facets of those key areas from enrollment, to education to participating in the acquisition of biometrics and even some back in touch points like automated outbound that said, you know, have you gotten to your refills filled on a Friday. Oh by the way, before you go to the ER, come talk to me first. So all of that we're seeing in the marketplace today.

Collin: One other point to that is, most of these tasks have to be manual. It's required that you cannot capitalize or facilitate the non-face-to-face time using technology. However, as Bob just spoke to, you can leverage the technology to better enable your care coordination staff so that their time spent on the phone isn't talking about grandma marries kitty cat. It's talking about grandma marries hare. So the whole point would be to better facilitate the conversation and dialogue between the care coordinator and the patients.

Another example of that might be a well-being survey that you could do through either web link, in a text message, or through a voice channel on an interactive voice response system to kind of assess where the patient is from a feeling standpoint so that way when I do call and talk to the patient, I know more about what's going with that patient and we can actually get down to the meat of it rather than talking again about grandma marries hare or her kitty cat.

Laurie: Okay. Christie would like some clarification. From what she understands, the only person who can bill is the primary care physician. So is it correct that if someone who works in the clinic with a licensure, like a social worker or nurse, if they call the patient to provide some care management, it's not billable time? Is that right?

Bob: Well remember that CMS lists those eligible providers that can bill for CCM. So there are...there's the ability then to assist in that care coordination program but you're not going to be billing under that individual's license or activity, per se. So it's still relegated to those identified providers that are eligible to bill. But again, the support of that billing can be done by individuals inside of your organization who are licensed to deliver on those types of services. So that's how I would frame up the two.

Collin: It's under incident to definition. So as long as I'm billing the time that I am as a medical assistant or a CNA, that's incident to the relationship that that patient has with the billing physician, then it can be billed.

Laurie: Okay, Nick would like to know how an emerging digital health company can integrate with West to help deliver value to shared customers seeking CCM solutions. He wants to know if there are APIs available for bi-directional integration that can be leveraged.

Bob: Short answer that is yes. So he can certainly reach out to our organization and absolutely we have APIs that can integrate.

Laurie: Okay. And Dr. Walker would like to know, he says, "Most practices want to do this, but they don't want to spend a lot of money on it or train the staff. Are there vendors at no cost to practice or what vendors are you working with that you recommend?"

Bob: Sure, and that's a great question because here's the challenge. Do physicians really want to create the infrastructure out of the box or is there alternatives to that to allow them to segue into value-based reimbursement? Because really, this the preface to that. So the answer to that is yes. There are organizations out there that can provide a turnkey solution with minimal impact to a physician's practice. What really then is required is a sharing of that reimbursement. So those are the models that we're seeing out there. So an example, specifically, if it's...I'm using a rough number here. But if it's $40 per patient per month, there's an opportunity for a physician to relinquish some of that reimbursement, not have the burden of setting up that infrastructure but still participating in CCM.

And it also gets back to Collin's point which is this is a way to test and try also as well. Or maybe learn from best practices as you engage a vendor in that arrangement, you ultimately then could create your own system and transition away from a turnkey system, per se, if that's the direction is the most applicable and profitable for the physician practice.

Laurie: Okay, great, well that was our last question. So with that, we'll conclude the webinar. I want to thank everyone for joining us today and thank you, Bob and Collin, for interesting and informative presentation. Attendees, watch your email for links to the recording of today's webinar as well as the PDF version of the PowerPoint presentation. We look forward to seeing at our next HIS Talk webinar. Enjoy the rest of your day.