Eliminating one CCM copay could save money by and improve patient care, advocates say

A physician office visit copay of as little as $10 a month has turned into a confusing, multimillion-dollar problem across Medicare.

But patients and physicians would benefit if Congress amends a rule to eliminate it, advocates say.

This year, AMGA, the American Medical Group Association, joined 39 stakeholder groups to endorse legislation to eliminate the beneficiary cost share for chronic care management (CCM).

The copay of $10 to $12 a month may not seem like much — but scaled out over millions of patients, it involves millions of dollars going to physicians, or not. Medicare staff have estimated up to 22.5 million patients could be eligible for CCM services, but just 4% are. While the figures add up to millions, advocates say there would be savings overall by keeping beneficiaries out of hospital care.

AMGA Senior Director of Government Relations Jamie Miller, MBA, spoke with Medical Economics about the situation and how congressional action could open up new patient care for beneficiaries and added revenue for physicians. The bill is known as the Chronic Care Management Improvement Act, and sponsors are Rep. Suzan DelBene (D-Washington) and Rep. Mike Kelly (R-Pennsylvania).

This transcript has been edited for length and clarity.

AMGA recently joined other health care and medical groups to endorse legislation introduced in Congress. Can you explain what that was?

Jamie Miller: Almost 10 years ago, in 2015 the Medicare Physician Fee Schedule created a chronic care management code, for physicians to bill the code so they could take so they could be compensated for 24/7 access to a nurse, chronic care management software. Taking care of a patient with two more chronic conditions can be very expensive, so Medicare created this code and it was great. But the problem was the U.S. Preventive Services Task Force determined that that code is not preventive. Therefore it's subject to a cost sharing, and right now it's like $10 to $12 per month. And why is that important? Well, if you add a cost share, what happens is that not as many people use the code. The latest data reveals that only 4% of Medicare beneficiaries for who are eligible for CCM use it. So that's about 882,000 out of 22.5 million eligible CCM beneficiaries. We worked with the great member of Congress named Suzan DelBene and she introduced a bill to waive that copay to allow more people to have access to care. AMGA’s perspective is, if Medicare is paying for this preventative care, the actual cost curve is going to go down. That's been our position all along. And now we have Mike Kelly, a Republican, who is supportive as well.

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Can you talk about the importance of managing those chronic conditions?

Jamie Miller: There was a Mathematica report that came out a couple years ago that said, fiscally, after 12 months use of the CCM code, Medicare was saving $72 per member per month, and also obviously the quality of care went up as well. So why it is important for our members and the people who signed the letter? Because health care is getting expensive, and you want to obviously take care of the patients. Why do we save money? Because they weren't going to the hospital, they weren't going to outpatient clinics, they weren't going to the inpatient clinics. They were either staying at home, having home care, telehealth services, other things. It's not just about good quality of care. It's not even about reducing the cost curve, but you're getting the patient in the right setting at the right time. And that's always been AMGA's perspective, because you don't want the patient going to the ER on a Friday night. That's bad for everybody.

What is an example of how that patient copay plays out in practice, when someone goes to see their doctor or maybe decides to skip going to see the doctor because of a copay?

Jamie Miller: I think why the copays are so complicated, because let's say you go to the doctor for, like, a cold, you pay a copay. The problem with this chronic care management code is that it's a non-face-to-face chronic care service, so the doctor is billing it every month, but you may not see the doctor every month. Let's say you have COPD, depression and another chronic condition. The doctor could bill a service, but a lot of times they don't because they know the patient can't afford it. So there's a lost opportunity right now because there is money in the system that isn't being used. And the whole chronic care management system was set up to bend the cost curve, and it's problematic when patient X in, let's say, Gainesville, Florida, is not able to use the chronic care management services, because people who can't afford $12 a month, they’ve probably have a lot of prescription drugs, they’ve got to pay for a lot of things that are potentially bankrupting them and maybe doing cancer care and other things. And so $12 may not seem a lot to certain people, but there's a lot of middle-, lower-income Medicare patients that just don't have the money to pay for that.

Why does this need congressional action, and why can't be amended with a policy rule or a dictate from CMS?

Jamie Miller: I'm sure you've dealt with the budget neutrality thresholds. This is going to cost around $790 million over 10 years. Congressional Budget Office scored that. And so when it comes to making CMS policy changes, if it's going to cost money, Congress has to be involved because they have to pay for the allocation. CMS doesn't have the money to do that, or the authority to spend additional monies. I mean, especially that big of a number. So that's why Congress is involved.

The $790 million is a lot of money in and of itself, but there is an estimated savings that would also take place. Could you make that connection again?

Jamie Miller: The Congressional Budget Office, we don't always agree with their economic outlooks. When it came to telehealth, AMGA was a big advocate for Medicare covering telehealth. (CBO estimated) that was going to cost every year $1 billion to $2 billion. And we just didn't really understand why, if Medicare is paying for telehealth, why would that cost additional monies? Because actually it's going to bend the cost curve because more people are getting access to care, they're getting access to preventive care. But CBO doesn't see it that way. So that's the same thint. If you eliminate a barrier like a copay, as CBO sees it, there will be more utilization of the code, and so that's the way CBO works. But the Mathematica report that I mentioned earlier, they did an analysis of people who did use the CCM code for two years, and like I said, the expenditures went down for that patient population. I think that's the problem with Medicare, telehealth and CCM, sometimes CBO doesn't always see eye to eye with providers and doesn't always agree with us that preventive care saves money. Maybe they agree in the long run, but not over the first couple years.

Hopefully better spending, finding the best ways to spend it really is going to be what advances health care in our nation.

Jamie Miller: Yes, and CCM, kind of like telehealth, having people have the access to care at the right time, the right place, is beyond the patient. It's also the caregiver. The caregiver could be their 50-year-old son who has to take a day off of work to drive them to the hospital. But if they had access to CCM services, there are probably less hospital visits, and honestly, the Medicare beneficiary would be in a better place in general. When you talk about altering Medicare policy, it's bigger than just the Medicare population. It goes into the caregivers as well.

If Congress approves the legislation, do you anticipate it would be an immediate action, or would this show up in like a future version of the Medicare Physician Fee Schedule? Or another way?

Jamie Miller: It depends. I would say congressionally, I don't envision this passing until the end of the year in some sort of package they need, like a lame duck session. I don't know if it would pass freestanding on the floor tomorrow. And in that case they would probably wait a year to waive the copay. If it passed in law in December, then the fee schedule would come out in June and it would probably become official a year later. But there have been times with CMS enacts things very quickly, like Medicare, telehealth, they did in three days. So you never know.

If it were to be approved, at the practice level, clearly there would be added awareness about the change in codes. But do you think that doctors would need additional staff, changes to their technology or patient outreach?

Jamie Miller: It depends on the group. I think a lot of AMGA members are very advanced and have the technological capabilities, probably because they're bigger and they're able to spread all the risk amongst the partners or the community. I think this will have a major impact upon like a one-, two-physician practice in Topeka, Kansas, like two primary care physicians who are barely keeping the doors open. That's why the American Academy of Family Physicians is a big, big fan of this. AMA is a big fan. AMGA members, they're not doing amazingly well, but they are able to move things around to pay for it, because they have so many different business lines. But if you're a primary care physician — not even a small town, but if you're like two people, you don't have the infrastructure to pay for these things. And so I think it would have a huge impact upon those small groups.

Our main audience is primary care physicians, what would you like to say to them, or what would you like them to know?

Jamie Miller: I would say, thank you for your support of chronic care management in general. I know that it's not easy taking care of anybody in general, but what primary care physicians do and how they serve the patient population, the health care system, is heroic and if they weren’t there — I hate to use this term, because Senator Ron Wyden uses it, who is from Oregon. He's a great guy, he always talks about basketball. He always says that the primary care physician is the point guard. It's true, they are leading the team. You go to a primary care physician, they send you the specialist, or they send you the pharmacist. No one else knows the patient as a whole. So just thank you for what you do, and we want to work to get this bill passed as soon as possible.