Are these 3 barriers keeping you from delivering better between-visit care?

Chronic Care Management can help medical groups deliver better care while creating a durable and profitable revenue stream — here’s how to overcome the most common barriers.

Patients with multiple chronic conditions require frequent care and support — and can comprise a substantial percentage of a physician’s panel: 70% of Medicare patients have 2+ chronic conditions. Physicians and advanced practice providers (APPs) have limited opportunity to impact patient health in just 3-4 office visits per year, so they and their clinical staff often spend substantial amounts of time providing uncompensated between visit care. 

Unfortunately, providers may not be able to afford to deliver proactive between-visit care to all the patients who might benefit. This is where Medicare’s Chronic Care Management program can help. 

Since 2015, Medicare has paid providers for delivering between-visit chronic care management services to Traditional Medicare and Medicare Advantage patients with 2+ chronic conditions. The program has been a top priority for Medicare: reimbursement increased 54% in 2022. CCM has been proven to improve quality and lower cost…

So why do only 3% of providers participate in CCM?

Medicare’s CCM program provides funding for between-visit care, but only 3% of providers participate. Moreover, the average panel size is tiny: just 41 patients per provider (median) – and many programs operate at a loss, adding additional financial strain to practices already struggling with costs that outpace reimbursement.

Many providers stumble on three barriers to success in CCM:

  1. Traditional approaches to patient engagement are ineffective
  2. Staffing shortages stifle program growth
  3. Patients concerns about co-pays may hamper enrollment

The good news is that these barriers can be overcome. Medical groups who build an in-house CCM service line can dramatically increase the number of patients who benefit from proactive care – while receiving fair compensation.

Barrier #1: Traditional approaches to patient engagement can be ineffective

Traditional models of care management can be ineffective at engaging patients. Care managers spend time calling patients, leaving voicemails, and calling back. If they are lucky, they may connect with a patient. It can take 3 phone call attempts to reach a patient on average.

Patients may only engage with a care manager once a month in this model, which gives the care manager limited opportunity to proactively intervene for better outcomes. Moreover, the monthly calls tend to be dry and templated versus having an engaging, on-going dialogue with the patient. 

Finally, after the calls the care manager typically spends another 20 minutes on time-tracking and documentation – hurting productivity.

Solution #1: Two-way texting is preferred by 95% of patients

Patients already text their friends and family – why not your practice? Almost all patients prefer texting – even elderly patients. When patients can easily connect with a care manager, they are more likely to engage: on average, 3.4 times per month. And when patients engage more frequently, they have better outcomes.

Texting is beneficial to patients because they can see and refer back to exactly what their care manager says, versus misunderstandings that may arise over the phone. Patients tend to open up more over text and be more honest about their health, because the ongoing text dialogue helps create a relationship between the patient and the care manager (and the practice).

Barrier #2: Staffing shortages stifle program growth

Healthcare finance expert Lucas Hutchison, MHA of Pinnacle Healthcare Consulting tells us labor costs represent 84.8% of total expenses for medical groups – and that’s if they can find staff to hire. 

Traditional approaches to care management are labor intensive and extremely expensive. A care manager equipped with the EHR and a telephone can typically manage a panel of just 50-100 patients. That 1:100 ratio forces medical groups to make tough decisions about which patients can have access to proactive care – even if many patients would benefit. And at this staffing ratio, programs don’t generate enough revenue to cover the cost.

Solution #2: Give care managers purpose-built tech and scale 10x

When care managers have the right tools, they can manage a dramatically larger patient panel – think 500 patients instead of 50-100 patients.

Texting facilitates multiple conversations in parallel, and smart tech helps care managers be more efficient with less effort – whether they are developing care plans or triaging issues. Working efficiently at scale leads to a profitable CCM program – which means more patients can get the help they deserve!

Barrier #3: Patient concerns about co-pays may hamper enrollment

Standard Medicare cost-sharing applies to chronic care management. This can be a concern for patients who are already struggling with multiple chronic conditions and may be on fixed incomes.

While only 2-4% of patients who unenroll do so because of concerns about a co-pay, it’s still important for practices to ensure patients are satisfied with the value of the services they receive.

Solution #3: Communicate with patients about CCM value

Ideally, Medicare would eliminate the patient co-pay for CCM. But for patients who may have co-pays, the key is communicating with the patient about the value of the program versus the cost. 

  • Patients have easy access to the practice versus having to navigate phone trees, wait on hold, or wait for callbacks.
  • Patients get concierge-level care management from someone they trust.
  • By getting the right care and avoiding a single ER or hospital visit, they more than make up for the co-pay.

Ensure every interaction has high value for the patient.

Medical groups need to carefully consider staffing, training, and workflow design to maximize patient benefit. Program managers starting from scratch – or not seeing desired results – should seek expert guidance to launch the program successfully and make sure care managers receive ongoing training and performance coaching. 

Practices should measure patient satisfaction at least twice annually to confirm that patients like the program and are getting value from it.

Communicate value clearly when marketing the program to patients.

From the start, medical groups should frame the program in terms of the value to patients: proactive care now prevents costly hospitalizations and emergency department visits later.

Best practices for program launch can ensure a 30% enrollment rate within 60 days; making sure patients clearly understand and consent to co-pays ensures they stay enrolled, engaged, and see benefits.

So why do only 3% of providers participate in CCM?

Medical groups that invest in an in-house CCM service line can:

  • Use technology to engage patients effectively and improve workflows
  • Improve staff productivity by 5x
  • Get to critical mass (enrolling 500-1000 patients) within 60 days
  • See 40% profit margins that can fund continued program growth
  • Deliver a service that enhances their most valuable asset: their patient relationships

But most importantly, an in-house CCM service line enables medical groups to invest in between-visit proactive care that can improve outcomes for their most vulnerable patients.

Director of Marketing

Alyssa believes that solving between-visit care is critical to effective population health management and long-term success under value-based models. For over a decade, she has worked with innovative health systems, large medical groups, and payers across the United States to help them implement programs and share their successes under advanced payment models.