By David Thill
Primary care docs take charge of chronic care management
Editor’s note: Demographics are changing. Venues of care are changing. Reps’ call points and the products in their bags are changing too. In this issue, Repertoire continues its series of articles on chronic care management.
Chronic diseases and conditions – such as heart disease, stroke, cancer, type 2 diabetes, chronic obstructive pulmonary disease, obesity and arthritis – are among the most common, costly, and preventable of all health problems. As of 2012, about half of all adults – 117 million people – had one or more chronic health conditions. One in four adults had two or more chronic health conditions. Seven of the top 10 causes of death in 2014 were chronic diseases.
At less than five square miles and a population of 10,230 at last count, the southern Nebraska town of Lexington won’t likely be making national headlines in the near future. But Dr. Brady Beecham’s patients at Lexington Regional Health Center are facing challenges similar to those of patients across the country, particularly when it comes to chronic disease.
Beecham, a family physician, estimates that about half of the 25 or so patients she sees each day are older adults with chronic conditions. About 117 million people, or half of all adults in the U.S., had one or more chronic health conditions as of 2012, according to the Centers for Disease Control and Prevention. And the cost is exorbitant: Eighty-six percent of the $2.7 trillion in annual health care expenditures is for people with chronic and mental health conditions.
Traditionally, treatment for patients with chronic conditions such as heart disease and cancer – which have long been the top two causes of death in the U.S. and together accounted for almost 46 percent of all deaths in 2014 – has fallen to specialists in many different areas of care. But as chronic conditions become more widespread, primary care physicians like Beecham are playing a more important role in orchestrating the care of these patients. With only about 15 minutes allotted for patient visits in many clinics, much of the work is done outside the clinic by nurses and other mid-level practitioners – but the primary care doctor is involved.
Beecham focuses first on prevention. “As primary care physicians, we’re really trying to be more systematic and careful about screening and diagnosing,” she says. This includes, for example, blood sugar screenings to determine a patient’s risk for diabetes.
For patients with one or more chronic conditions, the goal is to minimize complications, she says. For example, blood pressure management is important to keep diabetes in check. Since patients often visit the clinic just once or twice a year, Beecham makes sure she checks their blood pressure when they visit.
Empowering patients
About 1,500 miles east of southern Nebraska, Dr. Sophia McIntyre and her team at Hudson River Health Care – HRHCare for short – are also helping patients manage chronic conditions.
McIntyre is a family physician and the chief medical officer at HRHCare, a community health center that serves the Hudson Valley and Long Island. HRHCare’s patients – many of whom are uninsured and most of whom are below the national poverty level – face several challenges that limit their access to adequate medical care. Among these challenges is a lack of education about disease prevention and healthy living.
To address that issue, HRHCare offers patients with diabetes the opportunity to meet with a Certified Diabetes Educator. The CDE – usually a registered nurse or nutritionist – meets with the patient to address social, medical and financial issues that might not arise during a usual primary care visit, says McIntyre. But these issues can affect the patient’s understanding of their condition and their ability to adhere to their medication schedule.
For example, perhaps a patient works a night shift in a factory and doesn’t have a break where they can take their evening dose of insulin. The CDE might come up with a medication plan, coordinated with the patient’s primary care provider, that allows them to take their insulin at another time of day.
McIntyre also believes it’s important for patients to have an active role in their care. “What we’ve found is that by having patients empowered, they’re more likely to better self-manage,” she says.
For the past five years, HRHCare doctors have given patients blood pressure monitors to use at home. As a result, 71 percent of HRHCare patients are controlled for hypertension, compared with 53 percent nationally, says McIntyre.
Programs like this may be helpful for patients, but adequately reimbursing the primary care team for their time and effort is another matter.
The payment problem
Commercial insurers cover CDE visits at HRHCare, says McIntyre. Medicaid, however, does not. Nor does the program cover the diabetes education classes she would like to offer.
To subsidize the at-home blood pressure monitoring program, HRHCare relies on grant support from organizations like the local Department of Health, YMCA and the CDC. As it is, about 100 monitors are available for patients. The program would be accessible to far more patients if commercial insurers and government programs like Medicaid covered them, McIntyre says.
But insurers don’t cover these services for “uncomplicated” patients, she says. In other words, they don’t often focus on prevention. If insurers did address prevention, McIntyre believes expenses like the $320 billion spent on diabetes care each year could be reduced. “Why are we waiting for patients to have advanced disease before we cover these devices?” she says.
Lack of insurance is also a challenge for many of Beecham’s patients in Lexington. For the most part, pills are inexpensive, she says. But other necessary care, like insulin and certain equipment, is much more expensive. She recalls a patient who, in an effort to save money, made his own walker. “We really end up working a lot with suppliers” to try to make high-quality equipment like walkers, oxygen and hospital beds available for patients,” Beecham says.
Quality reporting programs, where payers cover monitoring and recording of information in patients’ electronic medical records, help encourage prevention of complications, says Beecham. Incentives like Medicare’s chronic care management program, which allows providers to bill for non-physician care outside the clinic, also encourage effective management, she says.
Since much of that management can be done by nurses and other mid-level providers, she can address more pressing patient concerns in the exam room. As a doctor, says Beecham, “it really is helpful to have that whole team helping to manage” chronic conditions.
David Thill is a contributing editor to Repertoire.
CPT codes for chronic care management
In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule for chronic care management services provided to Medicare patients who have multiple chronic conditions. In addition to physicians, certain non-physician practitioners can bill for chronic care management services, including certified nurse midwives, clinical nurse specialists, nurse practitioners and physician assistants.
The three chronic care management codes reimbursed under Medicare are:
- CPT 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation or functional decline
- Comprehensive care plan established, implemented, revised or monitored
- CPT 99487: Complex chronic care management services, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation or functional decline
- Establishment or substantial revision of a comprehensive care plan
- Moderate or high complexity medical decision making
- 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
- CCPT 99489: Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
Source: Centers for Medicare and Medicaid Services: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
Chronic disease: An overview
- Chronic diseases and conditions – such as heart disease, stroke, cancer, type 2 diabetes, obesity and arthritis – are among the most common, costly and preventable of all health problems.
- As of 2012, about half of all adults – 117 million people – had one or more chronic health conditions. One in four adults had two or more chronic health conditions.
- Seven of the top 10 causes of death in 2014 were chronic diseases. Two of these chronic diseases – heart disease and cancer – together accounted for nearly 46 percent of all deaths.
- Obesity is a serious health concern. During 2011–2014, more than one-third of adults (36 percent), or about 84 million people, were obese (defined as body mass index ≥30 kg/m2). About one in six youths (17 percent) aged 2 to 19 years was obese (BMI ≥95th percentile).
- Arthritis is the most common cause of disability. Of the 54 million adults with doctor-diagnosed arthritis, more than 23 million say they have trouble with their usual activities because of arthritis.
- Diabetes is the leading cause of kidney failure, lower-limb amputations other than those caused by injury, and new cases of blindness among adults.
The cost of chronic disease
In the United States, chronic diseases and conditions and the health risk behaviors that cause them account for most health care costs.
- Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions. These costs can be reduced.
- Total annual cardiovascular disease costs to the nation averaged $316.1 billion in 2012–2013. Of this amount, $189.7 billion was for direct medical expenses and $126.4 billion was for lost productivity costs (from premature death).
- Cancer care cost $157 billion in 2010 dollars.
- The total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity. Decreased productivity includes costs associated with people being absent from work, being less productive while at work, or not being able to work at all because of diabetes.
- The total cost of arthritis and related conditions was about $128 billion in 2003. Of this amount, nearly $81 billion was for direct medical costs, and $47 billion was for indirect costs associated with lost earnings.
- Medical costs linked to obesity were estimated to be $147 billion in 2008. Annual medical costs for people who were obese were $1,429 higher than those for people of normal weight in 2006.
- For the years 2009–2012, economic cost due to smoking is estimated to be at least $300 billion a year. This cost includes nearly $170 billion in direct medical care for adults and more than $156 billion for lost productivity from premature death estimated from 2005 through 2009.
- The economic costs of drinking too much alcohol were estimated to be $249 billion in 2010. Most of these costs were due to binge drinking and resulted from losses in workplace productivity, health care expenses and crimes related to excessive drinking.
Source: United States Centers for Disease Control and Prevention: https://www.cdc.gov/chronicdisease/overview/