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Medicare's push to improve chronic care attracts businesses, but not many doctors

Phil Galewitz

Holly K. Hacker

Medicare enrollees with two or more chronic conditions are eligible for Chronic Care Management, which pays doctors to check in with those patients monthly. But the service hasn't caught on. John Moore/Getty Images hide caption

Medicare enrollees with two or more chronic conditions are eligible for Chronic Care Management, which pays doctors to check in with those patients monthly. But the service hasn't caught on.

Carrie Lester looks forward to the phone call every Thursday from her doctors' medical assistant, who asks how she's doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and her other health issues.

Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression, fibromyalgia and hypertension.

"Just knowing someone is going to check on me is comforting," says Lester, 73, who lives with her dogs, Sophie and Dolly, in Independence, Kansas.

At least two-thirds of Medicare enrollees have two or more chronic health conditions, federal data shows . That makes them eligible for a federal program that, since 2015, has rewarded doctors for doing more to manage their health outside office visits.

But while early research found the service, called Chronic Care Management, reduced emergency room and in-patient hospital visits and lowered total health spending, uptake has been sluggish.

Federal data from 2019 shows just 4% of potentially eligible enrollees participated in the program, a figure that appears to have held steady through 2023, according to a Mathematica analysis. About 12,000 physicians billed Medicare under the CCM mantle in 2021, according to the latest Medicare data analyzed by KFF Health News. (The Medicare data includes doctors who have annually billed CCM at least a dozen times.)

By comparison, federal data shows about 1 million providers participate in Medicare.

$62 per patient, per month

Even as the strategy has largely failed to live up to its potential, thousands of physicians have boosted their annual pay by participating, and auxiliary for-profit businesses have sprung up to help doctors take advantage of the program. The federal data showed about 4,500 physicians received at least $100,000 each in CCM pay in 2021.

Through the CCM program, Medicare pays to develop a patient care plan, coordinate treatment with specialists, and regularly check in with beneficiaries. Medicare pays doctors a monthly average of $62 per patient , for 20 minutes of work with each, according to companies in the business.

Without the program, providers often have little incentive to spend time coordinating care because they can't bill Medicare for such services.

Health policy experts say a host of factors limit participation in the program. Chief among them is that it requires both doctors and patients to opt in. Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don't have a supplemental policy.

"This program had potential to have a big impact," says Kenneth Thorpe , an Emory University health policy expert on chronic diseases. "But I knew it was never going to work from the start because it was put together wrong."

He said most doctor's offices are not set up for monitoring patients at home. "This is very time-intensive and not something physicians are used to doing or have time to do," Thorpe says.

For patients, the CCM program is intended to expand the type of care offered in traditional, fee-for-service Medicare to match benefits that — at least in theory — they may get through Medicare Advantage, which is administered by private insurers.

But the CCM program is open to both Medicare and Medicare Advantage beneficiaries.

The program was also intended to boost pay to primary care doctors and other physicians who are paid significantly less by Medicare than specialists, says Mark Miller, a former executive director of the Medicare Payment Advisory Commission, which advises Congress. He's currently an executive vice president of Arnold Ventures, a philanthropic organization focused on health policy. (The organization has also provided funding for KFF Health News .)

Not "easy money"

Despite the allure of extra money, some physicians have been put off by the program's upfront costs.

"It may seem like easy money for a physician practice, but it is not," says Dr. Namirah Jamshed, a physician at UT Southwestern Medical Center in Dallas.

Jamshed says the CCM program was cumbersome to implement because her practice was not used to documenting time spent with patients outside the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice started getting reimbursed by the program.

Only about 10% of the practice's Medicare patients are enrolled in CCM, she says.

Jamshed says her practice has been approached by private companies looking to do the work, but the practice demurred out of concerns about sharing patients' health information and the cost of retaining the companies. Those companies can take more than half of what Medicare pays doctors for their CCM work.

Dr. Jennifer Bacani McKenney, who runs a family medicine practice in Fredonia, Kansas, with her father — where Carrie Lester is a patient — says the CCM program has worked well.

She says having a system to keep in touch with patients at least once a month has reduced their use of emergency rooms — including for some who were prone to visits for nonemergency reasons, such as running out of medication or even feeling lonely. The CCM funding enables the practice's medical assistant to call patients regularly to check in, something it could not afford before.

For a small practice, having a staffer who can generate extra revenue makes a big difference, McKenney says.

While she estimates about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants the calls, she says.

While the program has captured interest among internists and family medicine doctors, it has also paid out hundreds of thousands of dollars to specialists, such as those in cardiology, urology and gastroenterology, the KFF Health News analysis finds. Primary care doctors are often seen as the ones who coordinate patient care, making the payments to specialists notable.

A federally funded study by Mathematica in 2017 found the CCM program saves Medicare $74 per patient per month, or $888 per patient per year — due mostly to a decreased need for hospital care.

The study quoted providers who were unhappy with attempts to outsource CCM work. "Third-party companies out there turn this into a racket," the study cites one physician saying, noting that companies employ nurses who don't know patients.

Nancy McCall, a Mathematica researcher who co-authored the 2017 study, says doctors are not the only resistance point. "Patients may not want to be bothered or asked if they are exercising or losing weight or watching their salt intake," she says.

How outsourcing works

Still, some physician groups say it's convenient to outsource the program.

UnityPoint Health, a large integrated health system based in Iowa, tried doing chronic care management on its own, but found it administratively burdensome, says Dawn Welling, the UnityPoint Clinic's chief nursing officer.

For the past year, it has contracted with a Miami-based company, HealthSnap, to enroll patients, have its nurses make check-in calls each month, and help with billing. HealthSnap helps manage care for more than 16,000 of UnityPoint Health's Medicare patients — a small fraction of its Medicare patients, which includes those enrolled in Medicare Advantage.

Some doctors were anxious about sharing patient records and viewed the program as a sign they weren't doing enough for patients, Welling says. But she says the program has been helpful, particularly to many enrollees who are isolated and need help changing their diet and other behaviors to improve health.

"These are patients who call the clinic regularly and have needs, but not always clinical needs," Welling says.

Samson Magid, CEO of HealthSnap, says more doctors have started participating in CCM since Medicare increased pay in 2022 for 20 minutes of work, to $62 from $41, and added billing codes for additional time.

To help ensure patients pick up the phone, caller ID shows HealthSnap calls as coming from their doctor's office, not from wherever the company's nurse might be located. The company also hires nurses from different regions so they may speak with dialects similar to those of the patients they work with, Magid says.

He says some enrollees have been in the program for three years and many could stay enrolled for life, which means they can bill patients and Medicare long-term.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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Zambia visit shows SSW’s global impact

A UNC School of Social Work delegation saw how their research helped a nonprofit create jobs in rural areas.

A small delegation from the UNC School of Social Work visited the growing rural town of Solwezi (population 90,000) in the North-Western Province of Zambia in March. They came to learn about the impact of local women’s savings and credit groups and their financial literacy training.

The trip was coordinated by Gina Chowa and Rain Masa from the school’s center for  Global Social Development Innovations in partnership with longtime collaborator Mathias Zimba, executive director of  Rising Fountains Development Program in Zambia.

“As partners, we work together to identify ideas and practices that will change lives for the better,” Masa said. “Researchers and graduate students at the school can help build the evidence needed to demonstrate to policymakers, officials and the business community what is needed to  improve the lives of rural Zambians .”

Improving lives in six countries

Masa is an associate professor who also serves as GSDI’s research director. He has worked collaboratively on both economic security and HIV treatment projects with Rising Fountains, a Zambian nonprofit dedicated to improving the livelihoods of women and children in rural areas.

Masa emphasized how community involvement localizes these economic programs and increases their chance of success and relevance.

“Economic security is the focal point of our work,” said Masa. “We provide funding and, maybe more importantly, we are available to Mathias and his team for ongoing capacity support as well.”

Paving career paths

During the visit to her native Zambia, Chowa was visibly moved at the end of a day spent at a teen center and a church. The delegation heard from over a dozen enthusiastic groups of about 20 women each and the men who had joined in support of them.

“These people. This is why I do the work I do,” Chowa said.

Following the presentations, the delegation went to see the small business owners in action. These included a man who bought spare parts for just one bicycle and now runs a repair shop with several assistants, craftswomen who purchased a sewing machine and yarn to create and sell clothing, and a woman who uses a mobile phone and SIM cards to help townspeople make financial transactions.

“This is not about politics,” said one Solwezi community leader. “I stand in the middle in support of our people helping better their lives and those of their families.”

At the end of the visit, local residents piled baskets full of sweet melons, gourds and pineapples at the front of a small church as parting gifts.

“The bounty and generosity of spirit of the nearly 150 people of Solwezi whom we visited with earlier this month made a lasting impression,” said Alice Washington, a longtime member of the school’s advisory board.

Read more about the Zambia trip and support the UNC School of Social Work’s global partnerships by making a gift to the  Global Social Development Innovations Fund .

In a campus email, Lee H. Roberts wrote it's a privilege to interact with students and inspiring to learn about the diverse range of interests they're working on.

Career Treks event highlights public professions

School of Education students networked in Raleigh with representatives from 11 state agencies.

Global studies scholar aspires to diplomacy

After earning a master’s degree, Kat Goodpaster became assistant director of Carolina’s Russian Flagship Program.

Public Service Awards go to 7 people, 2 groups

The Carolina Center for Public Service honored work on health disparities, refugee aid and more.

UNC-Chapel Hill graduate programs ranked among best in nation

U.S. News & World Report’s 2024 “Best Graduate Schools” list named multiple Carolina graduate degree programs in the top 10, including UNC Eshelman School of Pharmacy at No. 1.

Broadway writer brings new comedy to PlayMakers

Fresh off the debut of her musical adaptation of “The Notebook,” Bekah Brunstetter ’04 will debut “The Game” in Chapel Hill.

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Research Instructor

Research instructor & executive coordinator.

• Physician, Faculty & Librarians
• Opening on: Apr 15 2024
• Public Hlth & Preventive Med
• State of New York
• Research Instructor HS, NSC6
• UUP (State University Professional Services Unit)

A master's degree in public health or related should be completed by the time of hire to qualify for an instructor-level faculty appointment. Working knowledge of public health. Experience in all of the following: project or grant coordination; peer-reviewed publication; presentation at scientific or academic conferences. 5 years experience in coordination and management in an academic setting, including purchasing, meeting coordination, human resource processes.

Some experience in course management and/or classroom lecturing at the graduate level. Experience managing graduate students and academic professional staff.

Some experience and/or training in both quantitative/statistical and qualitative research, data management, and literature reviews, with ability to expand skill set in one or more of these areas.

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We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran status or disability or other protected classes under State and Federal law.

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