Medicare’s push to improve chronic care attracts businesses, but not many doctors

Apr 18 2024KFF Health News Carrie Lester looks forward to the phone call every Thursday from her doctors' medical assistant, who asks how she's doing and if she needs prescription refills. The assistant counsels her on dealing with anxiety and her other health issues.

But while early research found the service, called Chronic Care Management, reduced emergency room and in-patient hospital visits and lowered total health spending, uptake has been sluggish. Health policy experts say a host of factors limit participation in the program. Chief among them is that it requires both doctors and patients to opt in. Doctors may not have the capacity to regularly monitor patients outside office visits. Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don't have a supplemental policy.

Jamshed said the CCM program was cumbersome to implement because her practice was not used to documenting time spent with patients outside the office, a challenge that included finding a way to integrate the data into electronic health records. Another challenge was hiring staff to handle patient calls before her practice started getting reimbursed by the program.

While she estimates about 90% of their patients would qualify for the program, only about 20% are enrolled. One reason is that not everyone needs or wants the calls, she said. Nancy McCall, a Mathematica researcher who co-authored the 2017 study, said doctors are not the only resistance point. "Patients may not want to be bothered or asked if they are exercising or losing weight or watching their salt intake," she said.UnityPoint Health, a large integrated health system based in Iowa, tried doing chronic care management on its own, but found it administratively burdensome, said Dawn Welling, the UnityPoint Clinic's chief nursing officer.

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