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Patients, Providers, Community All Benefit from Medicare Care Coordination Program

Care Coordination (Part 3)

Dr. Karen Smith, a family practitioner in Raeford, NC, is the perfect illustration of why Medicare’s Chronic Care Management program (CCM) is a large step in the right direction. In fact, the program is a triple win: providers get paid for work they were doing but not getting paid for, patients get better care, and the overall community lowers its healthcare costs.

Dr. Smith freely admits she and her staff were not being paid for the care they provided to chronic care patients outside of office visits. They knew it was a problem but did not see a solution until CCM came along.

Today, Smith employs care coordinators whose job is to conduct outreach to patients with chronic conditions via phone and the practice’s portal. This effort encourages people to become engaged with their care and encourages them to seek help when making decisions affecting their health.
Smith says the chronic care patients participating in the program are getting better outcomes than those who aren’t. One reason is providers are often able to intervene before a health problem becomes serious. And with more chronic-care patients staying out of the hospital, overall healthcare costs for the community are lower.

The American Academy of Family Physicians offers the follow approaches to getting started with CCM:

  • Identify Medicare Part B patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient.
  • Prioritize patients at highest risk of hospitalization or have recently been/are regularly seen in the emergency room.
  • Start with patients that regularly call into the clinic to manage symptoms or with medical questions.
  • Identify patients that may be most likely to benefit from care management based on the number of specialists involved in their care or who have limited social or local family support.
  • Identify patients dually eligible for traditional Medicare and Medicaid (not managed Medicaid).
  • Identify volume needed to hire additional part-time or full-time staff and then prioritize eligible patients.

There is one catch, however. Because of the level of documentation required, the CCM program was not really designed for small practices. Physicians who wish to participate in the program should consider partnering with an outside resource such as One Healthcare Solutions, which can provide care coordination services on their behalf.

The partnership shares in the additional revenues generated through CCM so that the program functions as intended: improving patient health and ensuring that physicians are paid for the work they do.

  1. “Connected Care: Physician Testimonial about Chronic Care Management,” CMS YouTube channel,
  2. “What is Medicare Chronic Care Management?” AAFP,
  3. “2018 Big Winners in the Medicare Chronic Care Management Program Rulings: How FQHCs, RHCs and other Provider Organizations Are Impacted,” eQHealth Blog, May 2018,

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