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Chronic Care Management A Building Block to Value Based Reimbursement


Good morning and thank you for joining us for our 11 a.m. CommonWealth Purchasing Group webinar with McKesson. I am Phil Dubois, Member Resource Consultant here at CommonWealth Purchasing Group. For those of you that are unfamiliar with our program, CPG is the leading group purchasing organization for community health centers and other nonprofit organizations nationwide. Here at CPG we negotiate savings and superior service from a portfolio of more than 75 nationally-recognized vendors. Our members save over 30 million dollars annually by utilizing our vendor contracts. Today we’re excited to have Bill Sillar, National Channel Manager at McKesson lead our discussion on chronic care management, a building block to value-based reimbursement. We’d like tohave this webinar be discussion based, so please feel free to use the raise your hand feature or type a question into the chat section at any time. After the presentation we plan to stay on for an additional 30 minutes to answer any questions that you may have for Bill or the team and I on the webinar today. Thank you for being here today. Let’s jump right into the presentation. Sounds good. Thanks Phil. I am Bill Sillar. I am the National Channel Manager at McKesson, business performances. I’ve been with McKesson for 10 years and one of the things that I help within McKesson is: I’m really looking at the transition from fee-for-service to value-based reimbursement to help our clients with that transition f from fee-for-service payment model to our value-based reimbursement payment model. This is what we’re going to be getting into today. So, first and foremost we’re going to take a quick look at what’s happening within the payment model structure and what’s happening within healthcare in the United States today, not only from the payment model perspective but also from our health perspective in our population perspective. Second thing will be going through is the Medicare Chronic Care Management Program, the requirements in the reimbursement incentives of that program. There’s been a few changes in there have been some proposed changes to that program and we’ll quickly discuss those in the third piece. First we’re going to go into how we can evaluate chonic care management for your own organization just to determine if it’s the right fit for you and if you want to go into that program. Second to last thing is we’ll be talking about how to successfully implement a chronic care management program from a staffing, technology, enrollment and the billing perspective, and then lastly we’ll be talking about your implementation options that you have going forward for successful chronic care management program. At the very end we’ll take on some questions too, so if you do have some things, just like Phil said, use that raise your hand feature and we’ll get to those at the very end here. To start us off, where we are at within the United States from the health care payment model perspective is that there’s two curves if you can think of it in this way. Curve number one represents fee-for-service and this is the curve that medicine the United States has always had. We’ve always had a fee-for-service model since the creation or since our medicine has started within the United State here. Curve two represents value-based reimbursement and where we’re at today within the United States is we are in between these two curves. Organizations have to keep their organization running by having enough fee-for-service patients in the door, while also looking forward in trying to jump on the curve number two at some point and get into that value-based reimbursement world. As we’re going to see in a couple of slides here, there’s a big shift in moving into that value-based reimbursement world within the last five years that we’re having organizations that are really having to make sure that they’re looking into that future because that’s where a lot of our largest players are moving into. Our largest paper that we have in the United States being Medicare. They are moving into a value-based reimbursement. It’s fact last year in 2015 the US department of health and human services, they were saying that in 2016 this year at 30% of all medicare payments were going to be tied to quality or value. So, they weren’t going to fee-for-service. there’s going to be a goal 30% percent and that was met and it’s actually been exceeded within this year already. They said also that in 2018 that 50% of all medicare payments are going to be tied quality or value through alternative payment models. That’s what ATM stands for. So you can see there’s like a rather large jump when we’re talking about two years of time that that’s going to jump up 20% that we’re moving from a fee-for-service world to a value-based reimbursement and what I mean by value-based reimbursement is that your payments will be tied more to quality as opposed to more of a volume-based fee-for-service world. Also, even the fee-for-service payments are going to have some sort of a tie to quality. 85% of fee-for-service payments are tied to quality in today 2016 and in 2018 that will jump up to 90%. So organizations really have to monitor to make sure that they’re going to be aligned with the quality incentives with Medicare just so that they can keep their doors open and if they can flourish. One thing to really note is if we look at the population perspective that by 2022 it’s predicted that Medicare beneficiaries are expected to compose 58% of provider volume across the United States. That’s not just for community health centers, that’s for the entire United States. That is a huge, huge amount of patients when you think about how much Medicare is going to be taking on in the future, and the reason for that is because of our baby boomers. This fits into that population that were looking at. Today within the United States there’s 55.3 Medicare beneficiaries that are covered and that was covered in 2015. By 2030, it’s predicted that that number is going to increase at 80 million people. So you’re having a huge increase of people moving into Medicare coverage within the next few years. For about the last eight years there’s been about 10,000 new Medicare recipients every day because of that baby boomer population. Couple of my co-workers called the silver tsunami, we’re having this huge bubble of population moving into that Medicare coverage. So it’s really increasing and that is why we have that 58% of provider volumes by 2022. One of the things that we should also mention is that back in 2010, Medicare took a study and they saw the writing on the wall. They saw that there was going to be this big burst of patients that we’re going to start coming in and they really had to look at where they’re spending was going. So they found that 14% of all their Medicare beneficiaries had six or more chronic conditions. So that 14% represents the sickest of the sick. They have multiple items that are chronic major problems that are going on with them. That 14% accounted for 46% of all Medicare spending in 2010. So if you think about that, that 14% is a rather small slice of the pie but that counted was a huge amount of spending in 2010. What Medicare wanted to do is they really wanted to look at that population and really try to prevent them from going into the hospital or having their conditions worsen so that it’s going to be a higher cost for Medicare spending. When they took a look at it, they found that more than two-thirds of that 55 million that we talked about had two or more chronic conditions. So, it’s a rather large portion of that population that has two or more chronic conditions. So really trying to go after that population with multiple chronic conditions because that is where the cost is most associated. If we look at chronic care management, this is a program that was rolled out last year and that it was not ruled out to community health centers and FQHCs and RHCs, it was only right rolled out to private entities. This year beginning of 2016, community health centers, FQHCs, and regional health centers could roll out the program and could receive the benefits for chronic care management. The goal of the program is to raise patient outcomes. So stabilize their health that they have, make sure that they’re not going to the emergency rooms, that their health is deteriorating, that they are some more of a preventative stance when it comes to these patients with multiple chronic conditions. The other thing from Medicare perspective is also the cost to save costs. Whenever you look at things from a treatment, or I’m sorry, a preventive stance as opposed to a treatment stance, you’re looking to save costs, pennies on the dollar is really what they’re trying to do with this program. So those are the two goals. Now how are they going to achieve these goals you may be asking. They’re going to really look at that patient population with two or more chronic conditions and like we mentioned before on the previous slide that’s two-thirds of that medicare population has a two or more chronic conditions. So that population that has the multiple chronic conditions, we want to be able to have some sort of a touch with that patient outside of your organization, outside of the four walls of the exam room. What we want to do is be able to talk about patient for 20 minutes a month to ensure that that patient understands what’s going on with their health care, so that they’re going to feel more empowered, more compliant, and that their health is going to improve outside of the the exam room is really the idea of it. So under CPT code 99490, Medicare is paying for non face-to-face care coordination services with those beneficiaries that have two or more chronic conditions. Who is going to perform that? So if we look at that box in the lower left-hand corner, these services are most likely going to be fulfilled by the clinical staff. That would be a nurse that would be calling the patient, a physician, we have some organizations that have pharmacist that are calling the patient, we have some organizations that have medical assistants that are calling patient. It has to be a clinical staff member. This would be built out underneath the provider. One of the other things I should mention is that you can also have a third-party perform these services for your patients. If you look to the financial reimbursement for this, what do organizations gain from a financial perspective by providing these services and that’s just from a Medicare perspective. We’re going to talk about what are some of the other benefits of having this program that are not related to financial portion but if a $40 reimbursement and that’s per number per month. So for any patient that you’re able to have that 20 minutes or more conversation with, your able to bill out that $40 to Medicare and receive the reimbursement for that. So that’s a quick rundown of chronic care management. If we take a quick poll question here: are you currently bill for non face-to-face chronic care management under CPT code 99490? So we wanted to take a quick look to see if anybody on the phone had been going through and had their own program running just to see how ahead of the game you are. Now remember that regional health centers, FQHCs, they were just available to roll out this program at the beginning of 2016. So it’s only been about 10 months that organizations have had to be able to start this program. So want to do a quick poll question there. So as you’re typing in those poll questions, what we’ll do here is we will move on and we’ll get into that and we’ll show those poll results here in just a second. Getting into some of the more details on chronic care management. So we have a good overview of what the program’s is looking to do and how its rolled out, but let’s dig into some of the details. So, first from a patient’s perspective, who are the patients that are able to qualify for this program? If the patients that have those two or more chronic conditions, they have to have traditional Medicare. We’re also seeing in some states that certain states are also opening up their Medicaid patients for this. So I would definitely take a look at your Medicaid population to see if they have multiple chronic conditions because they might be able to get some sort of benefit from this. One of the things that we should also mention is that Medicare is always the trendsetter when it comes to programs and how things are going to be paid out and a lot of the states are looking at Medicare right now to see the benefit from this program so that can potentially rollout this program in the future. Patients must have traditional Medicare. Patients also must provide their consent, so they have to fill out a consent form if they want to sign up for this program. The reason for that is because patients have a little bit of skin in the game when it comes to kind of care management. Medicare want patients to pay a copay 20% every month. If the patient has a secondary, or if the patient has Medicaid is their secondary that’s going to get covered by that secondary insuranc,e so I wouldn’t worry about that if you’re patient as a secondary, it’s only those patients that have traditional Medicare their primary and don’t have a secondary are the ones that would have to pay the $8 copay a month. Last thing is that patients can only participate in one providers program at a time. Medicare wants to have one provider that’s managing this patient because they have all these chronic conditions. They really want to have one medication list, they want to have one care plan so that everything is going through that one provider and that one provider is the central nervous system of it all. From a provider perspective or from an organization perspective, first and foremost all these records must be maintained in a certified EHR technology and certified being meaningful use certified EHR technology. Second piece: the provider or the clinical staff must explain the scope of chronic care management services to the patient and also how the patient can revoke those services. So at anytime the patient is unhappy with the services or they don’t want to pay the $8 copay, they can get out of that by revoking that through the phone call, through email, through whatever method that they need to be able to do. Third piece here is that patient have to come into the office in order to enroll into this program. Medicare want the patient to be seen for an office visit and that would be like a physical exam. So an annual well visit, an initial Medicare visit, or 99212 to a 99215. So any of those office visits, which are the majority of offices that a patient would be coming in for would be able to qualify that patient for the enrollment and then, if the patient wants to enroll in this program, they would sign the consent form and they would be good to go. Last piece is that organizations must provided on call service or 24/7 urgent care with access to the patient’s electronic medical record. The idea on this is if the patient has a concern that they need to go to the hospital, that they’re able to get ahold of somebody and that person is able to direct them that they can, that they should just make an appointment in the morning or maybe it’s something that they should go to the ER for. So that you have to have on call services to perform these chronic care management services. Let’s talk about some of the changes to chronic care management. So we’ve gone through the program pretty detailed so that you have a good idea of the reimbursement, what you need to do to implement the program from a high level and now we’ll talk about some of the changes that have been made to chronic care management and some of the proposed changes. In July 2016, CMS decided to relax two of the requirements for this program. That being providers had to have 24/7 access to their patients records. So this is a limit that providers have to be on call or anything like that, it’s just that on-call physician does not need to have immediate access to that patient’s records. So that’s what that is referred to. The second piece is certified EHRs is being used to share clinical care summaries for those patients. One of the big things when this program was first rolled out was that we wanted to have transfers of the records between all the providers that patient was seeing, that no longer is on being required. It’s not certified records are having to be shared, only the building providers are required to share records with other providers in a timely manner and that can be in many different manners. Moving on some of the other changes that we have and these are proposed changes. So I really want to underline that these are proposed, these are not set in stone yet. We should find out soon if these are going to have to come true with in 2017. First is they’re going to try to simplify chronic care management. The first thing is they’re going to not require the consent form anymore. If the patient wants to enroll in the program, all they would need to do is that the provider would need to document that in the record and again this is not set in stone yet, so this would take place in 2017 if proposed changes were to go through, but at this point patient’s still need to fill out the consent form. Also the initiating visit is relaxed. So new patients or established patients are the only one, and the established patients that have not been seen in 12 months are the only ones that would need to come in for a visit to sign up for this. So they’re really trying to open up the program, so they can hit the mass quantities of Medicare patients. Then the last piece is that there’s relax documentation, care plan, the access, and the format, really trying to open it up the organizations so that it’s not as strict on that piece of it as well, so that they can really start hitting all these different population bases and all these different organizations. So number one is simplification of chronic care management. The second thing that is proposed as a change to chronic care management is that there’s new billable codes. The other thing that’s been proposed that there’s going to be a higher rate that you would be able to receive a reimbursement from chronic care management in 2017. So really trying to push this program and really make sure that up organizations are getting a financial benefit from doing this. Also, there will be billable codes for patients that have behavioral health issues and there would be three added code that providers could bill out with those behavioral health. So if you have a patient that has some sort of behavioral problem and you’re able to counsel them on the phone and connect them with a mental health professional with the PCP, there’s some added incentive from a financial perspective there. Also, there is proposed code of postcodes for cognition and functional assessment. That’s great for those patients that have that dementia and Alzheimer’s, that you’re able to monitor those patients and receive some sort of financial incentive by doing this over the phone. Letter C is care plan development. One of the the bedrocks of this program is creating a care plan for the patient. It’s documenting all of those chronic conditions and making sure that those chronic conditions have goals and that were monitoring all of those things. If you have a patient that has six or more chronic conditions, it takes a long time to create that care plan and that is why there is now a care plan development code so that providers and organizations can get some sort of a reimbursement for not only being on the phone with the patient but doing the work outside of that phone call. Complex care management services, so if that patient has a lot of issues that is on the phone this is how you can get a higher reimbursement for a patient that has 10 chronic conditions as opposed to a patient that just has the two chronic conditions, there’s going to be a different amount of complexity that you’re going to discuss with those two patients based on that and there’s going to be different rates based off of the complexity, so not just a $40 reimbursement you might be able to receive higher reimbursement based on the patient’s complexity and the amount of work that you’re putting in. Right now, it’s just that $40 reimbursement when we’re talking about any patient. Letter E is the prolonged evaluation in E&M services. So if you have a patient that’s coming in and that’s a patient that is tied to chronic care management and the provider and the nurses are having to do a lot of work on that chart prior to that patient going into the exam room, you’re able to charge some time for that prolonged evaluation. So a lot of great changes that look like they’re coming into chronic care management just opened up and to give a little bit more of a financial incentive for organizations to provide these great services. Now let’s talk about if chronic care management is a good fit for your organization and even if it’s not a great fit for your organization, it’s a great thing to know and understand because as we can see within healthcare that’s where we’re moving. We’re moving to a preventative stance, where we’re trying to communicate with patients outside of the office and make sure that their health is not deteriorate, that they’re able to have some sort of a stabilized healthcare. The advantages to participating in this program in chronic care management is number one, higher quality of care. We’ve seen that in the short amount of time that this program has been out there since the beginning of 2015, we’ve seen that patients with those multiple chronic conditions are going to the hospital far less. They’re also improving overall and number one, they actually feel better themselves. When they’ve been surveyed over 50% of them say that have more power over their own healthcare and that they feel better about things. So patients are happier, patients are having a higher quality of care, they’re not going to the ER as much, which is great. You also have a new revenue stream. When you’re talking about the chronic care management, it’s a brand new revenue stream that you’re able to bring into your organization, but that also helps you with things like annual audits that gives you an incentive to get that patient in the door and to have them seen for that well visit. This is a way that you can get those patients into the office every year and to help that revenue stream. We call the paid-for petri dish, but this is really just helping you get into, value-based reimbursement, where you’re able to go into that area where you’re focusing on prevention and you’re focusing in on value and quality as opposed to the volume. Return on investment for outreach programs is really hard to quantify. With this program is very easy because you can see all the patients that you’re touching, you can see how many times that they’ve had an episode or if their care and their cost is going up or if it decreasing, you can really do some nice metrics on those types of things from this outreach program and it’s very easy to do because you’re staying in a fee-for-service world but you’re dabbling in that value-based reimbursement world. Also, the increase in primary care physician volume is something that we’ve seen our own clients have an uptick in. They’ve had their losing patients to the ER having those patients come back into their offices instead of going in there. So when a patient might think that, oh you know I really go to the ER now, when they talked to the nurse, they might find, oh this isn’t something that that critical. I can come into the offices as opposed to going into the ER. So the PCP volume does go up with this program. So there are advantages other than just the financial reimbursement. Some of the disadvantages to participating. So if we’re going to talk about the good, we also have to talk about the bad. So first is the devoted staff, the amount of people that you have that are devoted to this program is pretty large. When you’re talking about having a nurse, pharmacist, medical assistant on the phone with that patient, that’s a big investment when you’re looking at that. Technology needed having that documentation, having some sort of a chronic care management module that can monitor how long that you’ve been on the phone with that patient. It’s not required but it’s definitely something that is recommended so that you can track how long you’ve been on with that patient and your able the template out those care plans. That’s another investment that needs to take place. Also, if you want to make those care plans available to the patient down the road, that’s another thing that would need to be made available to the patient. Billing challenges. If you feel that collecting copays from patients going to be a challenge, then that might be something that you might want to steer away from, but actually the billing is pretty straightforward. It’s one CPT code at this point and the ICD-10 codes are reused. So from a billing perspective it’s very simple. The only big problem would be collecting co-pays and from the regional health center, FQHC base, I don’t know if you’re going to be collecting that many co-pays for some of these patients just because some of those will be late. Slow ramp-up. One of the big things that we found is that when you flip the switch and you go live with chronic care management, you still have to wait for those patients to come in the door and sign up for the program. So there is a ramp-up period where it takes before you’re going full speed with this program, and also the need for a strong clinical process. The communication between the nurse, the physician, all those types of things really need to be strong because you’re having that that extra resource that is on that phone with that patient and really needing to have that strong documentation and strong communication so that patient is not left in the balance. Let’s talk about what your patient population should look like if you wanted to really be a solid candidate for the program. So first and foremost, I would take a look at your Medicare patients first, and this is your traditional Medicare patient. I don’t think any of you might have that many Medicare Advantage, I might be wrong, but it Medicare Advantage plans are not paying on this. Its regional Medicare Advantage plans are having some some success with paying on this. It’s traditional Medicare is what the program was based on, was what it was created for. Some Medicare Advantage are paying for this but you would definitely want to talk to those local plans to see if they’re participating in this program or not. Second piece is if Medicaid is paying in your state for these services. We found that some are paying and that others are not. In the states that they are paying it a lot much lower rate than the $40 reimbursement and that’s because the copay is weight. So that rate would go down to about $36 and I’ve seen it in some states $32. Double check which, if your state is paying for chroinc care management services and then that is a good way to be able to quantify and also see what the reimbursement is to because that’s a good way to quantify if the program is going to be a good fit for you. Then we mentioned before that Medicare Advantage is plan-to-plan locally. So that’s another thing to investigate is to see how many of those patients that you have and how you can go through that. We’ll talk about the numbers and how those fit in with this and how to determine your provider how many patients that you should have if you want to move forward with this chronic care management program. We talked about previously that, when we look at the medicare patient population that 66%, two-thirds of them had that two or more chronic care conditions. So we look at it from a whole, you had two-thirds that fit in that bucket, the average enrollment rate that we’re seeing is about 25% and then some organizations are actually knocking at 25% out of the park and it’s about 40%. So I would say 25-40%. I would like to use the conservative on on this slide. So if you have one provider that manages about 300 Medicare patients, you would have 200 of those patients would be eligible and then the potential enrollment would be about 50 patients that we would forecast would be enrolled in this program. So that would be over the course of the year that you’ll be able to get 50 patients for that one provider that would have 300 Medicare patient signed up for the program and the idea of how you would be able to look at that. This is based off with just some of the national average that we seen once the program has been rolled out. Again, if you have that one provider and remember that would be with 50 patients that are signed up for chronic care management. The reimbursement for community health centers, FQHCs, regional health centers, is $40.82. If you are not an FQHC, or a regional health center, you would look at the Medicare fee schedule and its regional how you would be reimbursed for the program. Please, understand that you might not have that $40.82 reimbursement if you’re not a FQHC or regional health center. That is going to be local to what your reimbursement is, but the national reimbursement for FQHCs and RHCs is $40.82. If we have over 50 patients, the estimated revenue per provider would be about $25,000, $24,492 dollars is what that 50 patients would be able to generate from a revenue perspective over 1 year and again we talked about all the other benefits. Financial benefits is being one thing that you can really quantify quickly, but the stickiness to that provider and being able to have their help improve is the biggest thing. The quality of the health care improving is the largest thing that you’re going to see from this program. So we’ve talk about how you can crunch the numbers, how you can see if going to have enough patients that are going to make this model work. We normally say 300 Medicare patients per provider is a really good point that you want to stick to, to be able to get that 50 patients because that 50 patients per enrolled provider are the ones that you really want to go after. Now let’s talk about how you can successfully implement the program and I’ll try to go through this rather quickly since I know that we’re kind of getting up against time here. So we talked about how who can provide these services and whose the billing provider. So physicians can fulfil these services and then also advanced practice providers. The providers that can execute these services are nurses, medical clinicians, pharmacists ,and other potential clinical staff. So that just gives you an idea for who can perform these services and who can bill for these services. Moving on, you might be wondering through this whole presentation what is happening on that phone call. So when a patient is being called what are they talking about with that nurse? So for that 20 minutes of that monthly not face-to-face time, the bedrock of that conversation is that care plan and we mentioned before that’s just monitoring their chronic condition, setting goals, seeing how they’re doing compared to those goals. Another large piece is medication reconciliation. We’re trying to gather all of the medications from all the different providers that this patient is seeing and trying to get that on one list, so that the patient doesn’t have any complications with their medication. Also,transitions of care. Big piece is when that patient goes to an emergency room, there’s a huge percentage that they go right back into that emergency room. The transition of care get them out of that setting of care and try to get them safely out of it and get them back into their normal residence. Then care coordination between providers. This is making appointments for that patient, whether that an annual well visit back with their PCP or making an appointment with a specialist that patient needs. When care coordination services are provided to a patient they’re much more likely to go and have that appointment created for that other specialists and that access to care which is the big driver of this program, its one of big benefit for patients is the care coordination. Not only are they having their health improved, but their life made easier because they have somebody making appointments for them and exchanging records too, so that those records are coming back into the chronic care management providers records there. Moving on from accessing staffing expectation. We’ve talked about all the different clinical components with the program, but there’s also an enrollment piece. That enrollment piece shouldn’t be overlooked because if you don’t have any patients, then you’re not going to really be doing anything with a live program. So the enrollment pieces is also one where you need to be able to have a process that’s under two minutes to be able to introduce program and get that patients signed up. Talked about the clinical phone calls. About 1 clinical resource for every 250 patients is what we’ve seen as been the average. One of the things I should mention is that first chronic care management phone call is pretty big. We’ve seen it that it averages over 60 minute because there’s so many chronic conditions, so many medications. A lot of things are having to be discussed in that first phone call, so it is a resource hog. Care coordination is another one where you have one resource that would be taking on about 250 patients. Then the billing is very straightforward. You’re just having to collect that 20% co-insurance if that’s something that your patient population is going to be on the hook for. From a technology perspective it’s very easy with the system. The only thing that you would really need tp zero in on those care plans. Do you have a system that document those care plans, have some sort of a template for it, and then also document the time when it comes to these items. So that be that last piece, the conditions, the goals, the barriers in the treatment is what you have to have documented on that care plan and also the time you spent with the patient. Those being the big things that you would need to have from a documentation perspective and it’s recommended that you have some sort of chronic care management module, not a necessity, but it definitely recommend. Here’s a little bit about the enrollments, but it is a team effort. That’s one of the things that organizations usually put a lot of effort into the clinical piece of it and they don’t think about the enrollment piece of it and unfortunately if you’re putting all your money into the clinical piece, then you’re not going to have any patients to see in the clinical side, because you’re not going to have any patients enrolled, but it is a big team effort. Having that front desk, medical assistants, having the providers being able to provide all those questions for the patient. The goal being trying to do this under two minutes with introducing the program, talking to them about it and then also just going through the different requirements for the enrollment, that is a big piece that you want to have for this program. The billing, we talk about that it’s very straightforward with the codes and also collecting at co-insurance might not be that big of a problem based off of some of the patient population you might have. So let’s look going to evaluating your implementation options. This is our last piece and thenwe’ll take it over to questions. So this will be our last slide that we have here. If you’re thinking about going into this program, I would definitely think about if you want to go along with this program or if you want to have a collaborative partner, being having a third party like McKesson performing services for you, that would be something that would be in the collaborative partner section. So your time to value with go alone is going to be much longer than having a collaborative partner go about this with you. The upfront costs are going to also be much higher if you’re going alone with this, as opposed to come collaborative partners. A lot of them will have some sort of an implementation fee that it will be quite small and they’ll be a per-patient basis as what you would receive as a reimbursement on that, so there’s skin in the game on both the collaborative partners part and also the client perspective, so it’s one of those things that can really get you into that program. From a margin return on interest, or investment I should say, that there’s greater control when you go alone but it’s a fixed margin when you have a collaborative partner, so if you’re able to really control your costs, you can receive a larger margin when you’re looking at this service, where with a collaborative partner that’s really going to be fixed. Provider staff time is going to be high when you’re going alone because you’re providing all of those resources but with a collaborative partner you having low amount of staff time because you’re having a nurse from that third-party providing the services, you’re having somebody create those care plans, they’re taking a look at technology, they’re calling those patients, they’re making the appointments, they’re gathering all those records. You’re really just receiving the communication and how that patient is doing and receiving the records from the appointment. So you’re receiving the benefits but you’re not having to put in as much money, not having to put in as much time with that collaborative partner section of that. One of the things that I did mention that we do provide these services. So McKesson does have a nurse call center. We’ve been up with that 2013. We’ve been providing these services since the beginning of chronic care management. If you were to take on this chronic care management program with McKesson, you’d be assigned a care team that would have nurses, it would also have a nursing support staff, so that would be the people that would be making the appointments for the patient and gathering the records from that care coordination perspective and then lastly we have a non-clinical staff and that’s a quality team. We’re making sure that that quality of those phone calls and experience that the patient is receiving is going to be exactly what you would expect from a McKesson product, that you’re going to to receive the best quality because we don’t want that patient help to be in the mix. Also, we look at this service is an extension of your organization. We do not identify ourselves as McKesson, we identify ourselves as your organization when we’re calling on these patients and we found that we’ve had a lot of success through the last year and 10 months providing services to different organizations. So definitely if you’re looking to have a collaborative partner, would love to be your collaborative partner going through with chronic care management or any other type of nurse calling services when it comes to gap closure and helping out patients. With that I will end that conversation we’ll start getting into questions here. So, I really appreciate everybody I’m jumping on the phone, being able to listen to this conversation. It’s one that even if it’s not a great fit if you don’t have a lot of Medicare patients, it’s something to definitely investigate because you’ve seen that that’s where healthcare is going to. They’re going to this preventive model. From a Medicaid perspective, so it’s something to definitely keep your ear to the ground on because it’s going to potentially happen with all the different layers. So if we could unmute the lines or if we could going to some of the questions here. I am not able to view if there are any questions or anything like that, but if there aren’t any question that I really appreciate everybody’s time. Bill, thank you so much. That was an excellent and very thorough and detailed presentation. We do have a couple questions that have come in throughout the presentation, a couple that I was able to answer. Just as a reminder as I had mentioned to start, if you do have a question you could use the raise your hand feature in the program here or type into the chat box and we’ll get to your question that way. The first one we have here for Bill is: if a good portion of our patients are non-verbal, can the 20-minute care management conversation be with the caregiver rather than the patient and still be eligible for reimbursement? Gotcha. That’s a great question and unfortunately those patients, I think we just discovered a big gap in the service because the patient have to be a non face-to-face call or service. So it can’t be with the caregiver in front of the person, it actually have to be non face-to-face but if that person is nonverbal, if they have some sort of a way, maybe if it could be instant message or some sort of way that way our text I’ve even heard providers have been providing via that is another way that this could be done or Skype. Skype would be a good way to do this as well if you have non-verbal. Great, thank you Bill. So as another reminder here we are recording this presentation, so either later this afternoon or tomorrow morning, the presentation will be posted on our website and there will be an email blast that includes the slides and a link to that presentation. If you’d like to share this with colleagues or others at your health centers. Here’s a follow-up to that question Bill. It looks like many do not have the mental capacity and their caregivers is their only means of communication. Again, it kind of sounds like that maybe a loophole right now to not fit the exact requirements. One of the things I should mention is that they can speak with the caregiver, so if they have a son or a daughter or a have a designated caregiver that they’re working with, that is the person we can also be on the phone. I’m glad they asked, that the person have that follow-up question because that’s one of the things that we do as well. We would talk to the caregiver and provide the services that way. Great. Melanie we can follow up with you directly afterwards as well. Thank you for that question. We have another one here from Natasha. Is there a standardized care plan that should be used? if so where can we locate it? if not what are the care plan or components that are required and where the consent forms located? It’s a great question. I’m not aware there is a generic care plan template out there anything like that, but I can tell you what we use and our standard is that we first document all the patients chronic conditions and we use it’s more like a tree if you can imagine that, so the chronic condition, should say an upside-down tree I should say, so that chronic conditions at the very top and then what we have is goals that would be sprouting down from that kind of condition. From those goals, we would have any barriers that the patient would have that would not be able to meet those goals and then lastly we would have treatments that we would have attached to those different barriers so that that patient can overcome the barriers and go to those goals. So that’s really what we have from a documentation perspective. Our documentation goesfrom left to right, we would have the chronic condition, then we have the goals, then you have in different columns you have those items. So we would have the barriers, then we have the treatments. Excellent. Natasha hope that helps answer your question. Again, we’ll be sending this information out and contacting either us here at CPG or Bill McKesson directly for further information. You know at any time is definitely great way to get further questions that may come up answered. Looks like for the time being Natasha you do have a follow-up, you said thank you, is there a requirement on the frequency in which the plan needs to be completed? Every kind of that patient is on the phone with the nurse, the care plan is reviewed. So the first conversation might be very lengthy because you’re creating a care plan from scratch, but after that patient had that care plan in place, it’s just updates, because you’re monitoring how they’re doing compared to their goals. So once a month is one that being monitored and updated. Hopefully that makes sense. Bill, thanks again this was excellent presentation. Super-detailed, really glad you could join us here this morning. Looking forward to get this blasted out to what everyone as well. Perfect. I appreciate everybody’s time. Thank you and to CPG, thank you for having us participate with us. Absolutely. Hope that you all have a great day and we’ll talk to you soon. Thank you. Bye.

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