For Medicare Patients With Chronic Diseases, Cost-Sharing Is a Barrier

Chronic conditions account for 90 percent of health care spending in the United States. The Centers for Disease Control and Prevention also reports that 40 percent of adults in the United States are living with two or more chronic conditions, with cancer, diabetes, hypertension and heart disease at the top of the list. 

There is a proven way to effectively manage people with chronic conditions so they can achieve their best health — chronic care management. CCM consists mostly of additional services performed outside of an office setting to better coordinate care for Medicare beneficiaries with two or more chronic conditions. 

These services include recording of patient information using certified electronic health records technology, reconciling medications so that patients take the right medicine and the right dose at the right time and preventative health counseling as part of a larger, comprehensive care plan. While these services don’t always happen while the patient is in the doctor’s office, they are a vital part of streamlining care and improving patient engagement so that better health outcomes are achieved. 

This work gets results. According to providers and care managers, CCM services boost adherence to recommended therapies, improve the efficiency of clinicians and reduce hospitalizations and trips to the emergency room. Unfortunately, CCM services are grossly underutilized in America. 

Among Medicare beneficiaries, more than 35 million Americans suffer from multiple chronic conditions. But only 684,000 — less than 2 percent — of those beneficiaries made use of the CCM services benefit available through Medicare. 

How did this happen? When CCM was made part of coordinated care within Medicare, Medicare began reimbursing providers under a separate code in the Medicare Physician Fee Schedule. This code was designed to reimburse providers for mostly non-face-to-face care management. 

However, the creation of the code imposed cost-sharing obligations on the patient. As a result, Medicare beneficiaries are currently subject to a 20 percent coinsurance payment just to access CCM services. 

Much like the old weather cliché “It’s not the heat, it’s the humidity,” chronic care management has its own paradox. In this case, it’s not the code, it’s the coinsurance. 

AMGA strongly supported the creation of the CCM code because reimbursing providers for services outside of office visits encourages physicians to provide such services. But the code was accompanied by a coinsurance payment requirement, which our members report actively discourages patients from seeking out these CCM services, even though they would benefit with more effective management of their conditions. 

Most beneficiaries are not accustomed to sharing the cost for care management services, so they balk. Removing the cost-sharing requirements for these services will allow patients to focus on their treatments and care without worrying about their out-of-pocket expenses. 

The providers of AMGA understand the benefits of chronic care management services. Founded in 1950, AMGA consists of almost 450 multispecialty medical groups and integrated delivery systems, representing approximately 177,000 physicians who care for 1 in 3 Americans. Our member medical groups work diligently to provide innovative, high-quality, affordable and patient-centered medical care. Managing and coordinating the care of people with chronic conditions is an essential part of their work. 

Any system that fails to deliver services to 98 percent of intended beneficiaries needs to be reformed. That is why we have welcomed legislation from Congresswoman Suzan DelBene (D-Wash.) that would waive the beneficiary coinsurance amount and streamline the ability to deliver CCM services to Medicare beneficiaries who need it most. H.R. 3436, the Chronic Care Management Improvement Act, eliminates cost-sharing as a financial obstacle to treatment and care.

DelBene has described her legislation as “a common-sense action Congress can take that will make it easier for doctors and nurses to provide care coordination for their sickest patients.” 

The physicians we talk to daily agree. AMGA appreciates that DelBene recognized the need for reform and strongly endorses her legislation. Congress should enact this legislation as quickly as possible.


Jerry Penso, MD, MBA, is president and CEO of AMGA.

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