Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death in the US, killing more than 150,000 people each year. COPD is a progressive and incurable lung disease experienced in two primary forms: chronic bronchitis and emphysema.
More than 16 million Americans are diagnosed with COPD, and another 14 million are estimated as undiagnosed.
Providers utilizing Medicare’s Chronic Care Management (CCM) program concurrently with Remote Patient Monitoring (RPM) can help slow the disease’s progression, prevent exacerbations, and provide more timely interventions. This can lead to reduced mortality and improved quality of life for patients, as well as enhanced reimbursement for providing more active and personalized disease management.
Improving disease management for progressive conditions like COPD
COPD is treatable but difficult to manage when patients are out of the clinic. Over time, a patient’s condition can decline through worsening symptoms, acute exacerbations, and cycles of hospital admissions. It can be challenging for primary care physicians and pulmonologists to stay ahead.
Providers stage COPD across four levels. Stages 1-4 range in severity from mild to very severe.. Patients at stages three and four have a six to nine-year shorter life expectancy, reinforcing why early intervention and consistent oversight are critical.
Proper COPD management is essential to lowering patients' risk for complications and can help reduce the risk or severity of other chronic conditions, including cardiovascular disease, pneumonia, respiratory failure, Diabetes, and lung cancer.
COPD treatment requires ongoing maintenance and supervision. Engaging patients in smoking cessation, managing complex medication regimes, encouraging pulmonary rehabilitation, and knowing when and how to avoid flare-ups takes more time than most physicians and care teams can provide.
However, combining two Medicare programs can significantly impact a provider’s capacity to support patients through COPD management.
CCM reimburses for effective COPD management
CCM is a Medicare program that reimburses qualified providers for non-face-to-face services. It is meant for beneficiaries with two or more chronic conditions. CCM can meet the complex needs of COPD patients through:
- Personalized care planning
- Monthly remote touchpoints
- Education in lifestyle change and self-management
- Coordinating preventative care
- Navigating complex treatment regimes
For example, a care manager can ensure that COPD patients receive annual flu, pneumonia, and COVID-19 vaccines, critical to health maintenance. They may also help patients sign up for and actively participate in pulmonary rehabilitation, which has been shown to decrease mortality by 37% three months after discharge.
A care manager may arrange a consult with a pharmacist or nurse practitioner to educate patients on their complex medication regimen that may include:
- Bronchodilators
- Corticosteroids
- PDE-4 inhibitors
- Antibiotics
Through the Medicare CCM program, providers can bill under CPT codes for non-complex and complex care management based on the level of medical decision-making needed. Within these two categories, codes further reflect different lengths of time spent with patients and the level of physician involvement required.
Most importantly, Chronic Care Management provides access to a care team that gives patients a sense of security and support. Through a collaborative and goal-oriented approach, patients can experience fewer COPD symptoms and slower progression. This enables providers to deliver higher-quality, value-based care for more complex patients.
RPM provides patient data for proactive COPD management
Remote Patient Monitoring is another Medicare program. It reimburses providers for the use of digital devices that collect and transmit patient clinical data. The program also accounts for clinician time to review the data and make changes to the patient’s care plan. This can help care teams intervene if the patientdata indicates an exacerbation that could be detrimental to the patient.
In clinical studies, RPM improved COPD management, patient outcomes, and cost, including a:
- 65% reduction in unplanned hospitalizations per patient per year
- 63% reduction in cardiopulmonary hospitalizations
- 1.28 days shorter length of stay during cardiopulmonary hospitalizations
- 44.3% reduction in all-cause ER visits
- 44.4% reduction in cardiopulmonary ER visits
- 13.2% increase in total outpatient pulmonary provider visits
- 3.4% increase in total number of prescribed steroid courses
Studies have shown that RPM can shorten the time from when flare-up symptoms begin to clinical intervention, taking advantage of the seven-day prodrome window.
By collecting physiologic metrics through smart devices such as pulse oximeters, spirometers, or peak flow meters, clinicians can access real-time patient data and receive alerts when readings fall outside a desired range.
Combining Chronic Care Management with RPM to manage COPD helps providers take action and engage patients before symptoms progress e. Additionally, physicians can deploy less aggressive and less costly treatments, which can be more effective earlier, avoiding exacerbations and admissions.
patients tend to underreport COPD exacerbations. Through tracking real time patient data in RPM, care teams have better insight into what’s really happening with a patient, tracking trends over time. This can lead to patient education conversations and opportunities to improve self-management.
ThoroughCare enables complete COPD management via CCM and RPM
CMS encourages providers to leverage both CCM and RPM to help manage patients’ chronic conditions. Utilizing remote patient clinical data in COPD management gives clinicians real-world insights to identify when to intervene, close care gaps, or adjust the care plan.
RPM data provides evidence of whether the current approach to COPD symptom management is effective. Chronic Care Management offers opportunities to collaborate more closely with patients to enhance self-management and preventive activities.
ThoroughCare is a comprehensive software platform that supports end-to-end workflow and simplified billing for managing COPD through a concurrent CCM-RPM service.
ThoroughCare provides a structured approach to care management while enabling flexibility to meet individual patient needs. This includes:
- Enrolling new patient participants in CCM and RPM
- Creating and maintaining comprehensive patient care plans
- Ordering, registering, and managing RPM devices
- Coordinating device set-up on behalf of patients to ensure effective care management
- Meeting enrollment and tracking program requirements
- Automating device- and time-based claims documentation for auditing
- Assessing patient symptoms, condition barriers, and care goals to determine planned interventions
- Alerting care teams when RPM data is outside set patient parameters
Key questions answered
Why is COPD challenging to manage?
An estimated 30 million Americans have Chronic Obstructive Pulmonary Disease (COPD), and more than 150,000 die each year of the disease. COPD is a progressive and incurable lung disease that decreases lung capacity and a patient’s ability to breathe. Flare-ups create exacerbations and unplanned hospital admissions. Over time, these events hasten the disease’s progressions, leading to a greater risk of other chronic conditions and mortality.
How can care management and Remote Patient Monitoring help manage COPD?
Chronic Care Management and Remote Patient Monitoring work well together because remote devices, such as pulse oximeters, spirometers, or peak flow meters, provide real-time patient data to inform personalized care planning. These Medicare programs offer reimbursement for time and device management and larger payments for patients requiring higher levels of complex care and decision-making.
What are the benefits of CCM and RPM to improve COPD management?
Providers that offer a concurrent CCM and RPM program capture real-time patient data, monitoring the patient’s symptoms remotely and intervening quickly when clinical measures go outside a desired range. Through consistent and regular touchpoints with patients, care managers can help patients set health goals, provide coaching and education, improve self-management, and avoid COPD exacerbations and costly admissions.