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How Chronic Care Management Can Benefit Providers And Patients

A session led by Irina Koyfman, DNP, NP-C, RN, at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023 detailed the potential of CCM billing for physicians who are not currently doing it and recommendations for optimizing the process.

In the United States, more than half of all adult patients have a chronic condition, and 1 in 4 Americans have 2 or more. Coordinating adequate care for these patients can be time-consuming, and this was the reasoning behind the introduction of Chronic Care Management (CCM) to the CMS Physician Fee Schedule in 2015.

The main Current Procedural Terminology (CPT) code she focused on is CCM, which is billed monthly in 20-minute intervals and covers all of the care coordination activities that go along with treating complex patients with multiple chronic conditions. In 2019, she noted, CMS announced it had received positive patient and practitioner satisfaction feedback and cost savings attributed to the advent of CCM.

Still, because billing for CCM can be complicated, Koyfman noted that many physicians had stopped using it, prompting CMS to tweak the rules surrounding it, adding additional care management time beyond 20 minutes and no longer requiring a significant care plan change to bill for it.

In 2021, an additional code, Principal Care Management (PCM), was added to the roster. PCM, usually billed by specialists, can be billed for patients with 1 chronic condition and has a 60-minute-per-month minimum.

For CCM billing, patients with at least 2 chronic conditions that are expected to last at least 12 months or until the patient's death, or conditions that place the patient at a significant risk of death, acute exacerbation, or functional decline can be included. This can include anything—from asthma to diabetes, cardiovascular disease, depression, cancer, and many more conditions that fit the requirements.

There are numerous activities that count toward the minutes billed for CCM, including forming a comprehensive care plan, care coordination, medication education and reconciliation, lab reviews, preventative care reviews, scheduling, specialist referrals, and more.

"Honestly, everything that is being done [for] the patient outside of the clinic is chronic care management," Koyfman said.

There are a set of stipulations for physicians to adhere to, starting with having an initiating visit with the patient (ie, a Comprehensive Evaluation and Management, Annual Wellness Visit, or Initial Preventative Physical Exam) during which CCM is discussed. The visit should be billed separately.

Patients must also give either verbal or written consent to be treated under CCM stipulations, and they must be informed of potential billing implications from the patient cost-sharing perspective.

Once CCM is initiated, additional patient-facing provider responsibilities include assigning a designated care team member to the patient, maintaining a certified electronic health record, and providing some sort of coverage around the clock in case patients need assistance. Physicians must also form a comprehensive care plan.

All health issues must be in the care plan, not just those the physician is billing CCM for. This can include listing problems, prognoses, measurable treatment goals, assessment of patient cognition and function, symptom management plans, interventions, medical management, care coordination, and a periodic review schedule. Recently, environmental evaluation and caregiver assessment were added.

A major limitation of CCM is that it can only be billed by one physician per month, Koyfman noted.

"It's very important if you're going to think about implementing CCM and you call the patient, you want to ask, 'Is anybody else calling you?' And they'll say, 'Oh, yeah, my cardiologist. The nurse calls every month.'" In this case, whichever provider bills first would be reimbursed, and the second provider's claims would be denied.

Another important aspect is that only physicians and non-physician practitioners, such as certified nurse midwives, clinical nurse specialists, nurse practitioners, physician assistants, rural health clinics or federally qualified health centers, and hospitals and critical access hospitals can bill for CCM. Limited license physicians and practitioners like clinical psychologists, dentists, or podiatrists, for example, cannot bill for CCM.

Still, the clinical staff managed by the provider can provide the CCM services to patients under general supervision from the billing practitioner on an incident to basis.

Certain other codes can be billed with CCM, while others cannot, Koyfman noted. Transitional care and CCM can be billed together, but CCM cannot be billed with home healthcare supervision, hospice care supervision, or certain end-stage renal disease.

When implemented consistently, CCM can have a significant financial payoff for providers. If 100 patients stay on CCM for a year, for example, this could generate about $80,000 while also improving patient satisfaction with care, Koyfman noted.

Doing care coordination in-house vs outsourcing is another question, considering the workload of managing patients. Pros of outsourcing include quick implementation, a lower price tag because, no need for additional management, no need for any new technology platforms, and the scalability of outsourced help. Still, this option offers less ability to manage the team, less work visibility, potentially less integrity, less engaged providers, and less collaboration.

For physicians outsourcing CCM, it is crucial to evaluate the clinical team, technology platforms, billing practices, and fees. A clinical team with proper licensing, bilingual staff, open lines of communication, escalation protocol for incidents that need physician attention, the attrition rate, and their management.

"Why? I met a pretty large [CCM] vendor whose manager is… a veterinary technician," Koyfman recalled, eliciting a collective gasp from the crowd. "A veterinary technician was managing nurses."

Validating software is also important, with countless options of varying quality. The software's reporting frequency and thoroughness; availability of a consent template, care plan, and clock for timing; EMR integration; and the software's capabilities in terms of tracking multiple billing tracks are things to looks at. The fees also vary substantially, Koyfman noted.

Koyfman closed with a reiteration of best practices for successful and ethical CCM implementation that benefits both patients and providers, regardless of whether CCM is outsourced or done internally.

Regular team meetings, analysis of root causes of hospitalization and readmission, regular clinical conferences, and a designated person on the internal care team to be accountable for CCM activities—whether outsources or in-practice—are all key best practices, she said.

A range of challenges still exist in the space. Patient out-of-pocket costs can vary depending on insurance plans and lead to dissatisfaction, and patient reachout and enrollment can be challenging. Some patients may also not be engaged with CCM, or may agree at first but make follow-through challenging. In the same vein, providers may not be as involved with CCM as they can or should be. Verifying patient eligibility, which varies based on what else is being billed and whether another provider has already billed for it, is not always simple.

The Conservative Case For Teaching About 'Gender Identity'Opinion

When the Florida legislature passed the Parental Rights in Education Act last year, the corporate media went ballistic. But as Americans began to see through the stilted headlines about the so-called "Don't Say Gay" bill, they scratched their heads and became disturbed by how eager many seemed to defend teaching gender identity to kids in grades K-3.

But amidst all the hyperbole and hyperventilation, the bill's opponents overlooked the kicker clause. The law outright forbade instruction about gender identity in grades K-3, but it stipulated that for other grades it must merely be "developmentally appropriate." But last week, the Florida Board of Education issued a regulation stating that teaching about gender identity is never developmentally appropriate (except for in health classes that students can opt out of).

Once again, Florida has changed the terms of a national culture war debate. The question is no longer whether young children should be taught about gender identity; rather, the question is should schools teach it at all?

If by "teaching about gender identity" one means "presenting gender theory as fact," then the answer is certainly "no." Gender theory asserts a sectarian truth claim, and one which most Americans do not believe. We, as a society, have long decided that public schools may not teach children sectarian truth claims—even those that a majority do believe. Our schools may not teach, for instance, that Jesus Christ is the Son of God who died for our sins and that through faith in him their souls will be saved. So, too, our schools should not teach that everyone has a gendered soul distinct from, and not necessarily related to, their physical body, which compels moral deference and affirmation by society upon one's mere declaration that it is so.

But given the novelty and pervasiveness of the transgender phenomenon, there is a strong case for teaching the scientific and sociological facts about it. Schools teach about the paradigm-shattering insights of great scientists—how Galileo pioneered the heliocentric model of the solar system, how Newton intuited the theory of gravity, and so forth. Perhaps schools should teach about the origin of gender identity theory and tell the story of Dr. John Money.

Money claimed that because individuals with sexual development disorders could be brought up as either "gender," gender was therefore a social construct distinct from biological sex. This theory took the scientific community by storm. But one young scientist pointed out two inconvenient facts: (1) Money's conclusion did not flow logically from his premise, and (2) Money had no experimental evidence to substantiate his claim. Money then conducted an experiment on male twins, one of whose genitals had been burned off in a freak circumcision accident. Money persuaded the parents to raise that child as a girl, and then published results claiming that his experiment was a striking success. This cemented the status of the gender identity thesis in the scientific community.

Money's results, however, were fraudulent. The child who was raised as a girl experienced severe psychic distress and desisted. Later, both twins tragically committed suicide. The revelation of Money's fraud, however, did not dent the theory's credibility within the scientific community. (Depending on the grade level, teachers who teach about the origin of gender identity theory could choose whether to mention that Money allegedly coerced the twins to perform sex acts on each other and took pictures of it.)

The Creative Coalition in the Classroom at East Side Community High School on May 5, 2010 in New York City. Charles Eshelman/Getty Images

The CDC-endorsed "Guidelines for Comprehensive Sexuality Education" recommend that schools present fifth graders with information about puberty blockers. And perhaps that is appropriate—so long as it is done in a balanced and comprehensive way. Children could be taught that the most popular puberty-blocking drug was long used to chemically castrate sex offenders, and that blockers can cause permanent bone density problems, mood disorders, seizures, brain swelling, and cognitive impairment. They should learn that this drug has not been approved by the FDA for use with children experiencing gender dysphoria. And they should learn that those who take puberty blockers almost invariably progress to take cross-sex hormones, which can prevent those taking them from ever experiencing sexual satisfaction, sterilize them, and keep them hooked on synthetic hormones for life.

There is also a fascinating lesson to be learned in international comparative science. Children could be taught that after countries such as Sweden, Finland, and the United Kingdom conducted scientific reviews of the medical evidence surrounding transgender procedures on children, they all decided that because the evidence of harm was clear and the evidence of any benefit shaky, such treatments should be confined to rigorously conducted experimental research. By comparison, children could be taught that the "authorities" advising doctors in the United States to pursue these treatments have conducted no such scientific reviews. Rather, teachers should point out, the guidelines endorsed by the American Academy of Pediatricians were designed by a single doctor and apparently were not reviewed or fact-checked by anyone else in the organization.

Students should also be taught the debate about social contagion. They could read excerpts from Dr. Lisa Littman's study on rapid-onset gender dysphoria, a previously unknown phenomenon that currently presents in groups of post-pubescent girls based on internet-affinity clusters. They should certainly be taught the data about the high rate of comorbid psychiatric issues present in children with gender dysphoria, as well as the remarkably high rate of autism among those children. They can review the data and ponder why gender dysphoria is far more common in politically liberal locales than in politically conservative ones. And they should obviously be taught that, historically, almost all children diagnosed with gender dysphoria became more comfortable with their biological sex once they went through puberty.

Public schools should not inculcate any sectarian dogma or expound any doctrine. But they should present students with the facts and information they need to critically examine society and arrive at their own conclusions. There is a strong argument that straightforward, fact-based, balanced instruction regarding gender identity issues has a proper place in public school curricula. Still, one can't help but suspect that when framed as a question of information rather than indoctrination, the partisan politics of teaching about gender identity would be totally transformed.

Max Eden is a research fellow at the American Enterprise Institute.

The views expressed in this article are the writer's own.

Study Explores Ways To Increase Diversity In Medical Residency Programs

Leading national organizations focused on graduate medical education assert that losing the diversity gap is critical to ensure equity in medical education and health care quality. Nevertheless, evidence-based strategies and best practices to improve diversity, equity, and inclusion (DEI) in the biomedical workforce remain poorly understood and underused.

"We need to meet the needs of the people," said Jed Gonzalo, senior associate dean for medical education at the Virginia Tech Carilion School of Medicine (VTCSOM). "Diverse patient populations need diverse health care to help them meet their best outcomes."

Gonzalo was one of eight medical professionals who recently took a deep dive into what 29 graduate medical education programs, also known as residency programs, are doing to increase their diversity. The group did a qualitative analysis of applications for the Barbara Ross-Lee, D.O., Diversity, Equity, and Inclusion Award over a two-year period. The award, supported by GME's governing body, recognizes exceptional DEI efforts in U.S. Residency programs.

Based on a content analysis of these exemplary programs, the researchers identified 33 themes and placed them in broad categories such as recruitment, intentionally integrating DEI into the residency interview process, retaining residents who are underrepresented in medicine as faculty, using affinity groups as mentors.

"We have studies that show that minoritized individuals do better when they're being taken care of by clinicians who look like them, have similar experiences, or even an understanding of what life is like for them," said Azziza Bankole, professor of psychiatry and behavioral health, and chief diversity officer at VTCSOM. "Diverse learning environments help our trainees, our residents, our medical students, and students in other health professions as well."

"The importance of diversity has to do with the quality of the learning environment," said Arthur Ollendorff, associate dean of VTCSOM's graduate medical education and professor of obstetrics and gynecology. "I believe that medical education is part of a social contract. It is our duty to train physicians who can meet the needs of their communities."

As a physician for Carilion Clinic, Ollendorff is familiar with the health system's educational mission that includes training of residents. Being immersed in intense clinical learning, residents are following the examples of their attendings who are doctors who have completed their training and often play an active role in the education of interns, residents, and medical students.

"The hope is that training in a setting that values diversity will make all trainees more in tune to the needs and best approaches to all the patients we serve," Ollendorff said.

Recognizing the importance of DEI, VTCSOM has initiated numerous diversity programs in recent years, including MedDOCS, an after-school mentoring program for Roanoke high school students, Health Professions Enrichment Program, an educational outreach series for high-potential ninth and tenth grade students, the Diversity and Belonging series for students, faculty, and staff, and Mentoring Communities for faculty and students. In addition, the school partners with the Achievable Dream Academy, which gives students who are at risk of failure in school becuase of socioeconomic factors, a chance to succeed. The diversity, equity, and inclusion website has a complete listing.

"A lot of great work is being done here at VTCSOM," Gonzalo said. "We hope programs and sponsoring institutions will look at the list of strategies in our study and say, 'We could do this or that,' which is great. We hope the study will spark ideas. What I think is critical is that implementing strategies should be done with a systematic and thoughtful approach so that they are deep-rooted and enduring."

The strategies and best practices identified by the research group are intended to give graduate medical education programs ideas and starting points for developing their own DEI initiatives. Their report appears in JAMA Network Open.

More information: Dowin Boatright et al, Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs, JAMA Network Open (2023). DOI: 10.1001/jamanetworkopen.2022.55110

Citation: Study explores ways to increase diversity in medical residency programs (2023, April 27) retrieved 28 April 2023 from https://medicalxpress.Com/news/2023-04-explores-ways-diversity-medical-residency.Html

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