Michael Paul Gimness, MD, is one doctor who's been embracing chronic care management strategies for years – even since before it was incentivized by Medicare.

A physician at Plant City, Florida.-based Family Medical Specialists of Florida, Gimness said the new CMS rules have been a boon to his patients and his practice.

Since the beginning of 2015, the Centers for Medicare and Medicaid Services has reimbursed physicians for CPT code 99490, which covers non-face-to-face consults of at least 20 minutes for patients with multiple chronic conditions. Those might include Alzheimer's disease, arthritis, asthma, atrial fibrillation, cancer, COPD, depression, diabetes, heart disease, hypertension, osteoporosis or others.

With 36 million Medicare patients suffering from two or more of those chronic conditions, the prospect of being reimbursed per patient, per month for coordinating their care has significant implications for population health.

The additional $43? Gravy. 

But while the money makes it worthwhile, chronic care management is not without its challenges, Gimness said.

CCM reimbursement requires clinical summaries (demographics, meds, allergies) to be created in certified electronic health records, and the development of patient-centered care plans – made available and able to be exchanged electronically with the patient and with all practice staff.

Just seeing 18 or 20 patients a day isn't the ideal, he said. After all, "you're just taking care of the sick visits when they come in like that. What I was trying to get to at my practice was a population health aspect, where I'm taking care of the entire practice, and I can zero in on the sickest of the sick patients I need to get into chronic care, case management, home health."

Several years ago, Gimness would work to identify those patients on his own, poring over spreadsheets, sometimes with help from his EHR vendor, Allscripts.

"There's really no way for me, as an independent doctor, to really get a population health network onto my system," he said. "I was basically just manually doing it, getting checklists, trying to get everything done that needs to get done for the patients. But in a busy day, you're still missing things, as much as you try."

A while, back, a medical colleague who knew Gimness' pop health proclivities connected him with CareSync, which makes use of care coordination technology and 'round-the-clock nursing services to help providers outsource their CCM initiatives.

Communication with patients was key, he said. Gimness would explain to them: "This is what chronic care management is. I think it would be a benefit to you. Medicare is going to help pay for this. And it's an extension of my office. This RN is going to have access to you 24/7. She is an extension of me. These people who are calling you are an extension of my office staff. They're not physically here, but they're an extension of me."

Impressively, "I only had two people who didn't sign up for it," he said.

In the past year or so he's had "a great buy-in from my patients and also from the staff," he said. "They were glad because that reduced a little of the call volume."

If a patient calls at 2 a.m. CareSync will handle it, he said. "If they have a concern about a medication, that's taken care of; if it's something I need to know about, I get a page."

Gimness offers the example of one of his patients, who has both colorectal and lung cancer, as well as anemia. Since joining the CCM program, his data has flowed much more freely among his many providers and his engagement with his care has improved.

"He's chronically ill, in and out of the hospital. He was going to eight different providers in three different health systems. One of them, I have direct access to through my EHR but the others are just separate silos out there, and I can't get that information. When we set him up, CareSync went out and hit every single provider, got all of them to start sending data in to them."

Now, Gimness said, the patient "comes into his monthly meetings with me and lets me know. He says, 'Hey, did you check the CareSync? I checked it yesterday, and they have all the stuff from my oncologist.' I don't have it yet, but I log onto the CareSync portal and it's there. I can print it off, I can fax it to myself."

That's, in turn, has helped improved his health, he said. "Since we've gotten him involved with CCM, I'll send him to home health. He's been out of the hospital more than he's been in. Now, say that's an aggregate of my entire patient population. If we can lower that by 20 percent, that's a huge win because then we can use those resources for other things, like preventative care."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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