Susan Harkema

Over a decade, the Centers for Medicare & Medicaid Services (CMS) tested various value-based innovation models focused on improving primary care. Models like CPC, CPC+, and Primary Care First demonstrated that “comprehensive primary care can lead to reductions in emergency department and hospital visits while better meeting patient needs.” In 2024, CMS introduced new reimbursement opportunities for primary care practices through the 2025 Medicare Physician Fee Schedule Proposed Rule. Referred to as enhanced care management, Advanced Primary Care Management (APCM) is meant to support primary care physicians in their transition to value-based care. Ultimately, their goal is to promote longitudinal relationships between clinicians and patients while reimbursing for risk-stratified care management services.

More than 60% of older Americans receive help from unpaid caregivers; typically, these include family, friends, or neighbors. Engaging family as part of the patient’s overall care team has been shown to improve chronic disease management, including: Medication adherence Self-care Clinical outcomes Continuity of care Health literacy Readmission rates Emotional support and motivation We’ll explore the benefits of engaging a patient’s inner circle in managing chronic illnesses through care management programs. We'll also highlight when and how to involve informal caregivers in patient care and how ThoroughCare facilitates deeper family engagement.

The Centers for Medicare & Medicaid Services (CMS) created the Shared Savings Program (SSP) to encourage physician groups, hospitals, and other healthcare providers to support more coordinated, high-quality, and cost-effective care. SSPs focus on chronic conditions: Nearly 80% of Medicare spending is delivered to beneficiaries with five or more chronic conditions. Also, nearly 99% of expenditures are for beneficiaries with at least one, so these alternative payment models (APMs) emphasize chronic disease management. SSPs focus on care coordination: According to research by the RAND Corporation and others, effective care coordination is vital, considering that a single medical condition can require up to 50 interactions between the patient and their care team in three months. SSP participants work to streamline care, reduce duplicate or overutilization, and drive efficiency. SSPs focus on lowering the cost of care: Research shows that the average annual Medicare spending for beneficiaries with one or two chronic conditions is more than double that for those with no chronic diseases. Plus, Medicare expenses for beneficiaries with five or more chronic diseases are nearly nine times the average for a person with no diagnosed chronic conditions. SSP participants seek to decrease Medicare and beneficiary costs.

The Centers for Medicare & Medicaid Services (CMS) launched Z codes in 2015. They are a set of ICD-10-CM codes that identify non-medical factors that may affect a patient's health status or ability to fully benefit from treatment. They were released for billing and research purposes, yet no reimbursement is associated with their use. While the intention for Z codes to capture health-related risk factors like social determinants of health (SDOH) is a valid step toward improved health outcomes and health equity, research has shown increasing but scant use. Only 0.11% of all fee-for-service Medicare claims indicated a Z code, representing more than 1.2 million claims.

The US Center for Disease Control and Prevention defines health literacy as "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others." According to the US Department of Health and Human Services, only 12% of US adults have proficient health literacy. This shows that, across all levels of education, 88% of Americans have less-than-proficient health literacy levels.

The Centers for Medicare & Medicaid Services (CMS) created the Shared Savings Program (SSP) to encourage physician groups, hospitals, and other healthcare providers to support more coordinated, high-quality, and cost-effective care. Alternative payment models enable combinations of value-based and fee-for-service payments. With an emphasis on Traditional Medicare beneficiaries, the three APM initiatives are covered here.

A patient’s chronic illness journey is cyclical and complex. It's not a linear path but a continuous loop of pre-service, service, and post-service interactions with the healthcare system. Without adequate self-management, health literacy, and personal discipline, a patient’s health can deteriorate, and their condition worsens significantly. For high- or rising-risk patients diagnosed with one or more chronic diseases, care management offers six primary benefits.

Health plans have extensive experience with care management, technology, and pilots. However, what’s new is leveraging all three to better collaborate with providers to enhance Chronic Condition Management, engage and activate members more deeply, and facilitate overall cost savings. Research shows that all health plans offer care management programs regardless of size, location, and ownership. And, while these payors’ “internal evaluations suggest that interventions improve care and reduce cost, plans continue to report difficulties in engaging members and providers.”

Approximately 93% of primary care physicians wish they had support to better engage patients with multiple chronic conditions, according to a Quest survey. However, 85% feel they lack enough time to give patients the level of care they need. Only 9% believe their complex patients receive adequate care for their conditions. Despite these views, 77% of these same doctors have not implemented a Chronic Care Management (CCM) program to improve outcomes.

In the US, diabetes affects more than 38 million adults, making up 11.6% of the population, costing more than $306 billion in direct medical costs. Adults aged 65 and older represent 29.2% of people diagnosed and undiagnosed with diabetes, increasing by 1.2 million each year. After adjusting for age and gender, people with diagnosed diabetes experience 2.6 times higher healthcare expenditures.

Gastroenterology is a complicated specialty that helps patients with multifaceted clinical and quality-of-life issues. Yet, these providers face increased challenges, such as falling reimbursements, increasing patient demand, and physician shortages. In light of these trials, gastroenterologists need strategies to streamline effective gastrointestinal disease treatment and provide scalable and personalized care that enhances revenue.

The Centers for Medicare & Medicaid Services (CMS) has released the proposed rule for its 2025 Medicare Physician Fee Schedule. According to the CMS press release, this year’s updates and new programs seek to expand whole-person care, recognizing a person’s wellbeing, including physical and behavioral health, as well as social determinants of health and support for caregivers.

Chronic kidney disease (CKD) is growing in prevalence, impacting more than 37 million Americans. More than 100,000 of these patients begin dialysis each year and 20% of those diagnosed die from the disease or its complications. At an annual cost of $114 billion annually, CKD is one of the most expensive chronic illnesses. Because chronic kidney disease progresses through stages, Nephrologists provide ongoing monitoring, care coordination, and symptom management throughout a patient’s CKD journey. Much of that non-clinical time has traditionally been unpaid.

Health systems are looking for ways to improve care outcomes and patient experiences while building cash flow and enhancing pay-for-performance. Transitional Care Management and Remote Patient Monitoring offer concrete, evidence-based strategies to achieve these goals.

Patient retention is as much about what you do as it is how you do it. Most importantly, patients stay enrolled when the value that they receive meets their goals and priorities. Through powerful processes, evidence-based tools, and analytics – the “what” – and mindful patient-centered approaches – the “how” – care management teams can retain more patients and maintain a healthy roster of program participants.

When deciding to start a new care management program or scale an existing one, there are many questions to answer, including: Should I administer my own program or outsource it? Who on my team will drive the program and lead patient interactions? What technology will be key to its success? Will there be enough patient activity to amount to billable time? Who of my patient base will indeed take part, and how so?

An opinion piece in the American Academy of Family Physicians’ (AAFP) FPM journal identified care management as an “essential strategy” for success in primary care practices. Despite growing evidence demonstrating its potential to improve the health of the most at-risk patients, Chronic Care Management (CCM) adoption by rural providers has been slower than their urban counterparts.

Data integration and interoperability enable greater capabilities to capture and share patient information, supporting new models like value-based care management. Access to disparate data sources can streamline and improve the quality of information used in care planning and intervention. Integrated data from educational or evidence-based clinical sources supports accurate and timely patient engagement. Lastly, pushing data back out from systems enables broader team-based care, quality reporting, and communication.

Print/Save as PDF ThoroughCare’s analytics capabilities provide many reports and dashboards that help leaders and their teams manage all aspects of care management, including clinical, financial, and operational performance. This article will provide an overview of a specific analytics report within ThoroughCare. It helps providers identify missed claim submissions and additional revenue opportunities. The Missed Reimbursement Dashboard reveals missed revenue opportunities that care teams can...

Primary care is the foundation of US healthcare. It’s reported that primary care is the “only” area in which providing more services—such as childhood vaccines and regular blood pressure screenings—is linked to better population health and more equitable outcomes. Yet, primary care is struggling. Several drivers are making it harder for physicians to do their best caregiving and patients to receive the timely access they need. Components of an effective care management program are essential to reimagining primary care in the next five years.