An overarching shift has taken place over the past 100 years. It’s picked up speed in the last 20. Medicine has transitioned from a focus on infectious and non-communicable diseases to the prevalence of chronic illness.
The National Council on Aging (NCOA) reports that 78.7% of adults over age 60 have two or more chronic conditions, while 42% of adults overall have at least two, and 12% live with five or more chronic conditions. For those over 50, multimorbidity is projected to rise by 91% by 2050.
Recognizing the need to manage chronic disease effectively, the Centers for Medicare & Medicaid Services (CMS) launched its Chronic Care Management program in 2015 to incentivize care coordination for patients with chronic conditions. Since then, numerous studies and reports have verified its value to clinical outcomes.
Understanding CMS requirements around which chronic diseases and patient risk scenarios qualify for coverage is fundamental for success.
CMS launched Chronic Care Management to incentivize service coordination
Chronic Care Management (CCM) supports care coordination services outside of regular office visits, including:
- Capturing structured patient health information via assessments
- Creating and maintaining comprehensive care plans electronically
- Managing care transitions across care delivery channels
- Coordinating and sharing patient health information to support care navigation
Through CPT codes that reimburse for monthly touchpoints, the program seeks to provide more accessible, ongoing, and personalized support to Medicare beneficiaries. This can improve treatment, avoid high-cost and -acuity care channels, as well as transition primary care providers toward value-based care.
Which chronic diseases meet CCM requirements?
CMS provides the following guidance as to which chronic conditions qualify for CCM services:
“Eligible CCM patients will have multiple (2 or more) chronic conditions that are expected to last at least 12 months or until the patient’s death, or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.”
They provide a long list of conditions that could meet this criteria, including the top five chronic conditions in the US—heart disease, cancer, diabetes, obesity, and hypertension. However, any disease that meets the CMS criteria could qualify.
In addition to an expectation that the patient’s disease will last at least 12 months or until the patient’s death, CMS also outlines, alternatively, that two or more diseases could qualify if they are expected to put the patient at risk of death, acute exacerbation, decompensation, or functional decline. Let’s define these terms to understand better what types of chronic conditions to consider.
Acute exacerbation: The sudden worsening of symptoms or a flare-up of a chronic condition that can lead to severe complications or deterioration. An acute exacerbation poses a risk to the patient's current health status and could require immediate medical attention to prevent health decline.
For example, an acute exacerbation of COPD could present with increased dyspnea, worsening of chronic cough, and increased sputum production.
Decompensation: The deterioration of a patient’s health condition due to organ system failure or decreased normal bodily function. A patient’s compensatory mechanisms may be overwhelmed or exhausted, indicating a significant decline in health. Here, too, decompensation may require prompt intervention to stabilize the patient and prevent further decline.
For example, decompensated chronic kidney disease indicates a significant decline in kidney function, leading to fluid retention, electrolyte imbalances and the accumulation of toxins.
Functional decline: The gradual loss of physical or cognitive abilities, including challenges with mobility, self-care, communication, and essential capabilities. This decline impacts quality of life and could require medical support and intervention to maintain current health levels or independence.
For example, a patient with vascular disease may experience functional decline due to inadequate blood circulation. Symptoms like lethargy and reduced exercise tolerance can impact their mobility, self-care abilities, and overall quality of life.
CMS offers the following list of chronic conditions that could qualify for Chronic Care Management, noting that this list is not exhaustive:
- Alcohol abuse
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer (breast, colorectal, lung, and prostate)
- Cardiovascular disease
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Depression
- Diabetes
- Gastrointestinal disease
- Heart failure
- Hepatitis (chronic viral B & C)
- HIV and AIDS
- Hyperlipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Ischemic heart disease
- Osteoporosis
- Schizophrenia and other psychotic disorders
- Stroke
- Substance use disorders
The key to deciding if CCM could cover a patient’s chronic conditions is whether it will require ongoing medical management and support or significantly impact their health, longevity, and daily functioning.
CCM manages multimorbidity
While Principal Care Management, another CMS program, focuses on patients with a single chronic disease, CCM supports patients with multimorbidity—multiple chronic conditions.
Research demonstrates that many chronic conditions coexist, highlighting the importance of CCM in managing comorbid diseases and preventing further complications.
- For example, heart disease and stroke often coexist due to shared risk factors.
- Diabetes is often associated with hypertension, heart disease, and chronic kidney disease.
- Comorbidities associated with Arthritis include heart disease, diabetes, and obesity.
- Behavioral conditions have been shown to co-occur with other chronic conditions. Diseases such as cancer and chronic pain can often coincide with depression and anxiety.
Chronic Care Management improves multimorbidity management by integrating several key elements, including:
- Ongoing touchpoints that provide continuity between in-person visits
- Patient-centered care planning that focuses on the patient's unique circumstances, goals, and barriers
- Shared decision-making establishes the patient as a leader in decisions about their care and treatment
- Team-based care that emphasizes support from care managers, nurse practitioners, or pharmacists
- Care coordination to help patients navigate the healthcare system and remove barriers
ThoroughCare helps manage multiple conditions
Providers can manage care management programs with ThoroughCare. As a comprehensive software platform, ThoroughCare streamlines care management across all program types. We automatically account for Medicare’s rules and requirements while documenting service records.
Our end-to-end workflow simplifies program oversight, service delivery, and billing for Chronic Care Management by providing a structured, evidence-based workflow.
Key questions answered
What are the requirements for which chronic conditions can be managed under CCM?
CMS states, “Eligible CCM patients will have multiple (2 or more) chronic conditions that are expected to last at least 12 months or until the patient’s death, or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.”
While most patients enrolled in CCM have one of the five most prevalent chronic conditions—heart disease, cancer, diabetes, obesity, and hypertension—any disease that meets the CMS criteria could qualify.
What medical disease qualifies for Chronic Care Management?
CMS offers a list of chronic conditions that could qualify; however, it notes that it is not exhaustive. These diseases range from Alzheimer’s disease to arthritis, depression, hyperlipidemia, stroke, and osteoporosis.
The key to deciding if CCM could cover a patient’s chronic conditions is whether it will require ongoing medical management or significantly impact their health, longevity, and daily functioning.
How can Chronic Care Management help improve care for multimorbidity?
Chronic Care Management improves multimorbidity management by integrating several key elements, including ongoing touchpoints, patient-centered care planning, shared decision-making, team-based care, and care coordination.
When combined, CCM provides more accessible, ongoing, and personalized support to Medicare beneficiaries with the goal of improving treatment, avoiding high-cost and -acuity care channels, as well as transitioning primary care providers toward value-based care.