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Chronic Care Management | Health Plans

A Payor-enabled, Provider-driven Chronic Care Model

July 11th, 2023 | 8 min. read



Content Team

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There’s an expanding need for payors to collaborate with physicians and launch large-scale Chronic Care Management (CCM) programs. As the adult population continues to age, 60% of adults and 40% of school-age children already have one or more chronic conditions.

While health plans have been using care management for decades, the use cases for chronic care management are expanding. Today, payors are scaling their programs to meet a wider array of opportunities to improve outcomes, control expenses, and avoid unnecessary costs.

Now that both Medicare and private insurance reimburse for non-face-to-face services monitoring patients with two or more chronic conditions, provider-driven CCM is taking off. As payment models evolve and expand, provider-driven CCM will become more prevalent, useful, and address the needs of an ever-increasing population.

Payor CCM typically includes traditional features

Standard payor-led CCM programs tend to focus on conditions through coordinated care with an eye to early intervention, risk management, and member engagement.

Nurses, or care managers, connect with members via phone or virtual tools to establish a care plan that concentrates on lifestyle and self-management to improve health and lower the risk of chronic disease flare-ups. 

Whether managed by one or more team members, program leaders typically use software or platform to manage their program and populations, as well as to create, track, and report on individual member plans and progress.

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The value of CCM is expanding

Research shows that, for Medicare beneficiaries, CCM services save taxpayers $.41 per patient, even after paying a provider $.59 in fee-for-service reimbursements. 

According to Highmark Health, payors can use CCM interventions to save more than $800 per case, reducing readmission and inpatient days, as well as lowering post-acute utilization rates across skilled nursing, long-term acute care, and inpatient rehab facilities.

Payors are tapping into chronic care management as an approach that can deliver greater value to other populations and use cases.

How CCM is evolving

Since the Centers for Medicare & Medicaid Services formed the CCM program in 2015, there’s been greater interest in seeing more care delivered via CCM. The same holds for other health plans, including employer-sponsored and commercial.

Here are six examples of how chronic care management is expanding:

Value-based care: According to research published in JAMA in 2023, care management programs are progressively being utilized as a new foundational strategy to advance value-based care. Accountable care organizations, Medicare Advantage plans, and Section 1115 waiver programs increasingly create contracts and programs that revolve around chronic disease management. CCM is now required in many CMS Innovation Models.

Pairing CCM with in-home and RPM: CCM is being combined with in-home care and remote patient monitoring to maximize data points, as well as convenience and easier access via lower-cost delivery channels. As consumers become more comfortable with virtual and remote care options, omnichannel CCM will grow.

Addressing social determinants of health: Because social drivers greatly influence chronic conditions, payors are expanding their CCM programs to assess social risks and needs while broadening their ecosystem with external partners and community-based services.

Rising risk: Some health plans, either through traditional CCM or value-based care initiatives, are beginning to use care management to establish relationships with members considered “rising risk.” Engaging members earlier looks to reduce exacerbations and decrease further risk from chronic illness.

Specialized disease management sub-focus: Condition-based disease management is being added as a standardized sub-focus of CCM programs. These disease-specific tracks add a layer to CCM for conditions ranging from end-stage kidney disease to dementia. Intensive and tailored support from specialty-trained teams strives to enhance the quality of life for higher-risk members with complex or multiple chronic diseases.

Enhancing member experience: Today, experience-related measures can determine more than half of a health plan’s overall Stars rating, which has increased by 25 percentage points since 2020. In light of this shift, health plans are experiencing lower overall member satisfaction and Net Promoter Scores.®  According to the J.D. Power 2023 U.S. Commercial Member Health Plan Study, overall satisfaction fell by 13 points, and customer service satisfaction fell by 33. The Net Promoter Score® for new members is poor, with an average score of 6 out of 100 points. The average score for established plan members is 25.

Chronic care management programs offer the opportunity to engage new and existing members who live with chronic illness, providing greater value for premium dollars.

Recommendations for maximizing ROI from CCM

In 2021, McKinsey published a whitepaper about the untapped potential of payor-led CCM. They offered two recommendations that can have an outsized, positive impact on any payor’s CCM return on investment.

Per McKinsey, “many payors are dedicating 10% or more of administrative spend on care management,” but they could see a more significant ROI from their chronic care management programs. 

They estimate that “over 90% of value may be ‘left on the table’ by payors.” In fact, they estimate that payors could realize more than two-to-one ROI, reaping a $2 return for every $1 invested. And that the most successful payors could see a 2-5% savings from chronic care management.

Two of their recommended strategies include targeting multiple high-potential sources of value and right-sizing care management.

Targeting multiple high-potential sources of value

Payor care management programs should target several medical cost and revenue sources to increase value.

While most care management programs focus on preventable medical events – like self-management or medication adherence – other metrics, such as the site of care, unit price,  appropriate diagnosis, treatment, and management, should become a greater focus.

Also, McKinsey recommends targeted revenue sources of value, including “clinically appropriate and accurate coding.” They offer the example of a care manager who believes that a member has possibly progressed to the next stage of chronic kidney disease. That care manager would be empowered to coordinate an appointment with a nephrologist to diagnose and appropriately code the increasing condition.

Another example of where CCM can add value is by closing care gaps that can improve Consumer Assessment of Healthcare Providers and Systems (CAHPS) performance. Gap management can influence Star ratings and a plan’s quality performance and member experience.

Lastly, CCM can support buy-ups as well as member attraction and retention. Payers may offer chronic care management as part of an increased coverage option. Companies with employees living with chronic conditions could benefit significantly from a plan enhancement that improves the employee experience.

Right-sizing care management

A review of care management programs by researchers across academic medical centers in Boston, including Harvard, was recently published in JAMA. The authors concluded that value-based care management should move from historical cost and utilization management to a more patient-centered care management continuum. This CCM continuum would be matched to their specific needs.

McKinsey’s work supports this as well. 

Rather than focus CCM on reducing utilization for a narrow subset of complex patients, they suggest that modern chronic disease management can help less complicated or “rising risk” patients. The program can be tailored to members’ needs.  

Members with low social or medical complexity may do best with a targeted, low-touch, condition-specific program. If their condition evolves and worsens, they could graduate to care management delivered by a multidisciplinary team well-versed in holistic, complex care.

Creating various intensity levels right-sizes attention and resources on the member’s current needs with flexibility for the future.

Finding new value points and ROI from chronic care management

Health plans continue to lead the industry in novel and practical approaches. Chronic care management has been proven effective at improving member health outcomes and controlling utilization and cost. Payors looking to scale their success have a variety of use cases where CCM could maximize value.

How ThoroughCare supports chronic care management

ThoroughCare’s intuitive software platform can help providers collaborate and deliver digital care coordination and chronic care management. Our solution can help: 

  • Streamline the creation of patient care plans 
  • Support staff workflows with guided, validated assessments
  • Help motivate patients through clinical recommendations
  • Analyze patient risk factors and generate clinical recommendations
  • Identify behavioral health conditions
  • Track and log services for an audit-proof record of care

Additionally, ThoroughCare supports comprehensive integration with leading EHRs, health information exchanges, remote devices, and advance care plans, while helping providers visualize and interpret patient and operational data through analytics

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