Highlights of Outreach and Collaborative Efforts of the
Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO)
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Managing Chronic Medical Conditions and Mental Health Concerns |
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Although people of any age can be diagnosed with a chronic condition, individuals 65 and older are more likely to be diagnosed and treated for one or more chronic diseases, according to the National Council on Aging (NCOA). Data from the Centers for Medicare & Medicaid Services (CMS) states that over 85 percent of older adults in the U.S. suffer from one chronic condition, and 65 percent of older adults suffer from two or more. With multiple chronic diseases and the potential for complex treatment decisions, healthcare coordination between patients, their primary care physicians, and other specialists is essential to managing chronic illnesses.
According to the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), an office of the Centers for Disease Control and Prevention (CDC), chronic diseases and mental health conditions are responsible for 90 percent of the $1.4 trillion spent annually in the United States. Throughout their lifetime, some individuals may acquire chronic medical conditions accompanied by mental health concerns.
Fortunately, Medicare’s benefits include options that can help older adults manage chronic diseases and mental health concerns. This week’s issue of The Livanta Compass focuses on principal care management (PCM), chronic care management (CCM), and behavioral health integration (BHI), three Medicare programs aimed to improve the lives of Medicare beneficiaries.
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Chronic Illness: By the Numbers |
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Chronic diseases, such as high blood pressure, diabetes, cancer, and heart disease, have a substantial impact on health and economic costs in the U. S., according to the CDC. The CDC defines a chronic condition as a condition that lasts a year or longer and directly limits or affects an individual’s ability to conduct normal daily activities. The CDC posted the following startling statistics on its website:
- The leading cause of death for Americans is heart disease and stroke—two of the most common chronic diseases in the U.S., responsible for over 877,500 deaths yearly. Additionally, heart disease and strokes cost more than $200 billion annually.
- Over 1.7 million individuals are diagnosed with cancer each year, and it causes nearly 600,000 deaths annually. Cancer treatments are rising and are expected to continue that trend, reaching $240 billion by 2030.
- Diabetes affects over 37 million individuals in the U.S. Prediabetes, often the precursor to type 2 diabetes, affects another 96 million people. Diabetes can cause other serious chronic illnesses like heart disease, blindness, and kidney failure. The cost of diabetes was $327 billion in 2017.
- As one of the most prevalent chronic conditions that is a source of chronic pain, arthritis affects nearly 1 in 4 adults, or 58.5 million people in the U.S. Arthritis costs in 2013 totaled almost $303.5 billion, of which medical costs accounted for $140 billion.
- Nearly 5.7 million individuals in the U.S. are affected by Alzheimer's disease. With 1 in 10 older adults affected, Alzheimer's is the fifth leading cause of death for older adults. As of 2020, Alzheimer's care cost an estimated $305 billion and is expected to reach over $1 trillion by the year 2050.
NCCDPHP, “About Chronic Disease”
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Principal Care Management |
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Although there is often a significant emphasis on managing two or more chronic conditions, individuals with one chronic disease may be eligible for an additional benefit from Medicare. Principal care management, or PCM, is a Medicare Part B benefit that helps beneficiaries manage a single complex chronic condition. This condition must be expected to last at least 3 months and cause the beneficiary a higher risk of hospitalization, physical or cognitive decline, or death. This benefit enables healthcare providers to work with Medicare beneficiaries to create a care plan for chronic disease and adjust as needed.
CMS, “Principal Care Management Services”
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What is Chronic Care Management? |
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According to CMS, chronic care management, or CCM, refers to healthcare coordination services that occur outside a regularly scheduled office visit. The Rural Health Information Hub (RHIhub) states that services include telephone and secure messaging communication, interaction with the beneficiaries' other healthcare providers, and care setting transition management. CCM enables providers to be compensated for 20 minutes or more of CCM services. Significantly, beneficiaries can access qualified healthcare providers 24 hours per day, 7 days per week, for urgent needs.
Only one provider per beneficiary may bill for CCM services each month. Healthcare providers are incentivized to participate in this program because, in many cases, they are already providing these services to their patients. Still, now they can bill Medicare and be reimbursed. CCM aligns with patient-centered care standards and may also increase patient satisfaction. Another potential benefit of CCM is a likely reduction in healthcare utilization, including emergency room visits and dependence on costly therapies.
To be eligible:
- Medicare beneficiaries must have at least two chronic conditions;
- the chronic conditions must be expected to last at least 12 months;
- these conditions must place the beneficiary at high risk of death or functional decline;
- the beneficiary must provide consent, either verbal or written, after an in-person appointment with their provider; and
- the beneficiary must be aware of the cost-sharing responsibility per Medicare Part B.
Eligible providers include physicians, physician assistants, clinical nurse specialists, nurse practitioners, certified nurse midwives, federally qualified health centers, rural health clinics, and critical access hospitals.
CMS, “Health Equity Programs: Coverage to Care”
CMS, “Chronic Care Management Services”
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Depression and Mental Health Among Older Adults |
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According to the CDC, one in five adults over 55 live with at least one mental illness, with depression being a common disorder among older adults. In fact, depression is more common in older adults with chronic disease, which can lead to adverse health outcomes, according to the NCOA. When an older American becomes a Medicare new enrollee, one of the benefits is called the “Welcome to Medicare” preventative visit. This one-time benefit includes screening for potential risk factors for depression. Additionally, traditional Medicare beneficiaries are given an annual depression screening under Part B (Medicare Advantage may differ based on the individual plan).
The conditions of this screening require that it must be performed by the beneficiary’s primary care physician and is only available once per year or every 11 months. The screening will last approximately fifteen minutes and includes administering a screening tool, interpreting the results with the beneficiary, and discussing any recommended treatment. The screening will test for the severity of depression symptoms and may include a referral for a formal diagnosis of depression. Although Medicare does not require one screening tool over another, the American Psychological Association (APA) provides a list of tools on its website that many providers use to conduct annual depression screening.
NCOA, “Suicide and Older Adults: What You Should Know”
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What is Behavioral Health Integration? |
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According to CMS, behavioral health integration, or BHI, is a care management service intended to improve the mental and behavioral health conditions of older adults in the U.S. Through CMS updates to billing codes as part of the CY 2021 MPFS Final Rule (CMS-1734-F), healthcare providers are enabled to bill and receive compensation for BHI services more accurately. These updates are based on the Psychiatric Collaborative Care Model (CoCM) and the General BHI care model.
CoCM can be used when a beneficiary's condition is not improving and involves a team of 3 practitioners to deliver care. General BHI refers to any care models other than CoCM involving behavioral health integration. These services typically include regular monitoring and assessment of the beneficiary, revisions of the patient's care plan, and regular interactions with the beneficiary's care team member.
An eligible beneficiary must have a mental or behavioral health condition, including substance abuse and psychiatric disorders, the provider believes needs BHI services. Patients must consent before a provider consults with specialists and be informed that cost-sharing applies to in-person and remote services.
CMS, “Behavioral Health Integration Services"
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Livanta Partners for Education |
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Did you know Livanta works with other Medicare contractors to facilitate education and outreach? One of Livanta's partners, WPS Government Health Administrators (WPS), will host a free educational webinar on Chronic Care Management and Depression Screening. To advance health equity, WPS is offering this webinar to educate and empower patients, patient advocates, and Medicare community members about the benefits of Chronic Care Management and annual depression screening. Given a challenge by Medicare to increase the utilization of Chronic Care Management and depression screening among Medicare beneficiaries, WPS created a webinar to educate and empower members of the Medicare community, including healthcare providers, about these benefits and methods to increase their use which could have an impact on improving health equity in these areas.
The webinar will be hosted by WPS on February 28, 2023, from 11:00 AM to 1:00 PM CT (12:00 PM to 2:00 PM ET).
To register for this webinar, use the link below:
Once registration is complete, a calendar invite with the link for the webinar will be sent to the email used to register.
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Coronavirus Disease 2019
(COVID-19) Resources
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Additional CMS Resources
Medicare and Coronavirus
Coronavirus Waivers & Flexibilities
Medicare Claims During Public Health Emergencies
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Additional CDC Resources
What's New & Updated
Health Equity
El COVID-19 y su salud
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12-SOW-MD-2023-QIOBFCC-CP243
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