What is Chronic Care Management?

Of the trillions of dollars spent annually on healthcare in The United States, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) estimates that 90% is spent on managing chronic and mental health conditions. Managing chronic conditions can be difficult for patients and their healthcare providers, but when they are managed properly, costs can be reduced, quality of life improved, and patient satisfaction increased. This is where Chronic Care Management becomes important.

What is Chronic Care Management?

Chronic Care Management (CCM) is a fee-for-service program that was introduced by Centers for Medicare & Medicaid Services (CMS) in 2015. CCM was developed by CMS to improve care for patients with multiple chronic conditions in the primary care setting. CMS felt that a program like this was necessary due to the number of adults in the United States with chronic conditions. According to data from the 2018 National Health Interview Survey (NHIS), more than half of adults in the United States have at least one diagnosed chronic condition and approximately 27% have two or more.

Among the 65+ Medicare population, 58.5% have multiple chronic conditions.

Centers for Disease Control and Prevention

CCM allows providers to bill for non-face-to-face care management services that happen outside of office visits. Billable services include development of a care plan, care coordination activities, telephone calls or emails, managing care transitions, or even coordinating with at-home and community-based providers. CCM can only be initiated after patients have an initial face-to-face with their provider and sign a consent. To receive pay from CMS, primary care physicians, or other qualified health professionals, must provide at least 20 minutes of CCM services per month.

According to CMS, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants can all bill for CCM services as well. Although these services can be carried out by registered nurses or care managers, it must be done under the supervision of the billing physician.

Who is included in Chronic Care Management?

Patients with two or more chronic health conditions are eligible for CCM. Chronic conditions are defined as those expected to last a year or more and increase risk of exacerbation, decompensation, function decline, or death. Examples of chronic health conditions include:

  • Alzheimers
  • Arthritis
  • Respiratory illnesses such as COPD or asthma
  • Heart conditions or hypertension
  • Cancer
  • Diabetes

When properly executed, a Chronic Care Management program can be a win-win.  At its core, patients get improved access to care, and providers improve patient outcomes while creating a significant new stream of revenue.

Benefits of Chronic Care Management for Providers

  1. Chronic Care Management is another avenue of revenue for primary care providers. In the first year after implementation of CCM, CMS reimbursed providers roughly $52 million for their services.  For the general CCM patient who requires care planning and general monitoring and oversight, physicians can earn at least $43 per patient, per month. For more complex CCM patients who require at least 60 minutes of clinical staff time per month, practices could earn $94 per patient, per month.
  1. Improved care for patients. CCM improves care coordination and use of proactive medicine. When patients are able to talk to their providers about prescribed medications and given tools to manage their chronic conditions, we can reduce medical expenses and decrease emergency department and hospital utilization. 

Benefits of Chronic Care Management for Patients

  1. Chronic Care Management improves support between office visits. In a recent national survey of Medicare patients enrolled in CCM, patients reported better communication from their provider and felt they had more opportunities to discuss health concerns outside of the office. Patients also stated that they found the monthly check-ins from their care managers to be a helpful reminder to pay attention to their health.
  2. Improved access to care. Chronic Care Management offers patients 24/7 access to care and ensures continuity of care. Additionally, they receive personalized care plans that take into consideration their medical, functional, and psychosocial needs.

Netrin Chronic Care Management Program

As part of Netrin Health’s integrated care management approach, we assist practices with navigating Chronic Care Management and delivering whole-person care through establishing care plans for patients, monitoring their progress, and determining when there are gaps or lapses in patient care. Improving the quality of care and reducing healthcare costs with better patient-provider communication – it’s the primary focus of our Chronic Care Management Program here at Netrin Health.

The following patient success story is an inspiring testament to how our CCM Program had a tremendously positive impact on a patient’s life with the help and direction of our multidisciplinary care management team.

Mrs. Johnson* is a patient of Dr. Jonathan S. Plotsky who recently moved to Maryland. She is a long-time diabetic looking for a podiatrist, dietician, and online diabetes education program. As part of Dr. Plotsky’s Chronic Care Management services, Mrs. Johnson was assigned a Netrin Health care manager who discussed goals and created a care plan. Through her care manager, the patient has found a podiatrist close to her home who could order diabetic shoes and manage her ongoing foot care. The care manager also referred Mrs. Johnson to the University of Maryland Diabetes Network which offers diabetes patient education classes through Zoom. Since moving to Maryland, Mrs. Johnson has been able to keep her blood sugars at or below 100 mg/dL. She is now focusing on managing her hypertension and will be enrolled in Netrin Health’s Remote Patient Monitoring program.


Chronic Care Management is a necessary tool for patients with chronic conditions. CCM Program enables patients to manage their health and reach quality of life goals through regular interactions with their primary care team while the providers sustain a higher level of care by getting reimbursed for the interventions and time needed outside of traditional office visits.

Are you interested in implementing Chronic Care Management? Contact us today to learn more about Netrin CCM Program and start the transformation of your practice.

*Patient’s real name has been hidden in this article for privacy reasons.

Adler, N. E., Cutler, D. M., Fielding, J. E., Galea, S., Glymour, M. M., Koh, H. K., & Satcher, D., 2016. Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care. NAM Perspectives.

N/A. Health and Economic Costs of Chronic Diseases. Centers for Disease Control and Prevention.

Boersma, P., Black, L., Ward, B., September 17, 2020. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Centers for Disease Control and Prevention.

Medicare Learning Network, July 2019. Chronic Care Management Services. Centers for Medicare & Medicaid Services.

Schurrer J., O’Malley A., Wilson C., McCall N., Jain N., November 2, 2017. Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services: Final Report. Centers for Medicare & Medicaid Services.