The Chronic Care Model (CCM) that emerged in the 1990s was a model designed to retool primary care and implement critical components to proactively manage patients with chronic conditions.[1] However, the model could not keep pace with the sickening of our population (e.g., cancer, heart disease, diabetes, addiction, etc.). Today, most sick patients present with multiple chronic conditions (now called “multi-morbid”) and increasing psychosocial complexity. Most alarming is that these patients face growing and overwhelming risks resulting from the sum of uncoordinated responses to each of their diseases.

Defining the Problem: It is estimated that 145M people in the US have at least one chronic condition and 100M are multi-morbid with two or more. Those 100M patients represent 71% of current healthcare spend.[2] 15M of those are living with cancer.

The Federal Response: In January 2015, CMS began reimbursing clinicians for providing internal care coordination services to Medicare’s sickest beneficiaries under CPT code 99490 – chronic care management and under CPT 99487/99489 for complex, chronic care management for multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. This move offered hospitals and physician practices an unprecedented opportunity to improve care, better manage populations while ultimately boosting the bottom line. However, this effort has not caught on.[3] In a study published in the Annals of Internal Medicine in 2015, it was estimated that healthcare practices that billed CPT code 99490 for chronic care management services could expect an annual practice revenue increase of more than $75,000 if a minimum of 50 percent of eligible patients were enrolled in the program. That’s no small new revenue stream.[4] There have to be serious reasons why providers have chosen to leave it on the table. The reason is likely that there is no information technology currently focused on CCM and CCCM to support this work. “Multi-morbid care management is way too detailed, disease-specific and off-label for the standard EHR.” Says Robert Bridwell, MD, Medical Director of Appian360, a care management company.

The cancer example in the 71%: Cancer care is complex, and made more so by the fact that most of its patients are multi-morbid. Multi-morbidity affects all phases of cancer care from diagnosis and treatment through to end of life care. Cancer is also a chronic condition. According to Dr. Bridwell, “Early, accurate, and comprehensive diagnosis is the bedrock of effective care for people with cancer. It is therefore critical to address multi-morbidity in oncology treatment planning and employ enabling technology to cohesively coordinate care. Many clinical tools are currently available for assessing the presence and severity of comorbidities. Essentially, integrating multi-morbidity status during planning prior to treatment coupled with technology-driven care coordination can promote better outcomes, likely reduce the cost of care, and ultimately improve the patient’s experience with their care. “

The interaction between pre‐existing physical performance ability and multiple medical conditions can delay diagnosis, can impact treatment efficacy, complicate survivor care, and impact decisions about starting and ceasing treatments.“The current single illness-focused care model isn’t always sufficient for the continuum care of individuals with cancer,” says Horng-Shiuann Wu, RN, PhD, associate professor at the Goldfarb School of Nursing in St. Louis, MO. “The entire oncology team needs to be educated about how to manage comorbidities,” Wu says. “Educating patients about working with their primary care providers and developing plans for managing those illnesses during cancer treatment are vital. Patients need to be instructed to continue the treatment regimens for non-cancer health conditions, like how to manage their hypertension and/or diabetes during chemotherapy.”

The ultimate solution: Care teams simply need visibility & access to the full disease list for their patients – to include information information on the patient’s multiple conditions and how the key monitoring of those conditions interact with one another or how they might react to drug regimens. For example, many cancer chemotherapeutic regimes include glucocorticoids which may exacerbate a co-morbid diabetic condition. Other therapies, such as androgen-deprivation therapy (ADT) with luteinizing hormone-releasing hormone agonists for prostate cancer, are linked with increased risk of the development of type 2 diabetes, possibly due to loss of insulin sensitivity. There must be an information technology platform that: 1) Identifies co-morbidities 2) Provides connection and awareness to these, as they relate to the primary diagnosis 3) Engages the patient in recognizing potential symptoms or issues common with their multi-morbid care and 4) Supports CCM and CCCM revenue capture requirements.

[1] The Chronic Care Model (CCM) originated from a synthesis of scientific literature undertaken by The MacColl Institute for Healthcare Innovation in the early 1990’s. During a 9-month project funded by the Robert Wood Johnson Foundation (RWJF), an early version of the Model underwent extensive review by an advisory panel of experts and was then compared with the features of leading chronic illness management programs across the U.S.[2] Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook.[PDF – 10.62 MB] AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed November 18, 2014.
[3] Manny Oliverez, Chronic Care Management Reimbursement: Why Aren’t More Doctors Billing for It? JANUARY 31, 2017
[4] Sanjay Basu, MD, PhD; Russell S. Phillips, MD; Asaf Bitton, MD, MPH; Zirui Song, MD, PhD; Bruce E. Landon, MD, MBA, MSc, Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study20 OCTOBER 2015.