Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions.



  • Chronic Care Management (CCM) is a critical component of care that contributes to better outcomes and higher satisfaction for patients. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM takes time and effort.

  • CMS Established separate payment under billing codes for the additional time and resources you spend to provide the between-appointment help many of your Medicare and dual eligible (Medicare and Medicaid) Patients need to stay on track with their treatment plans for better health.

  • CCM payments can be made for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation/decompensation, or functional decline.

Research - Survey Findings - More Needs To Be Done

  • Two thirds of all Medicare beneficiaries have two or more chronic conditions.

  • Of those surveyed 66% of primary care doctors say they don’t have time to address social and behavioral issues, such as loneliness or financial concerns, that could affect the health of their patients.

  • 44% of Patients tell their doctor about other medical conditions, but not other issues they are facing that could affect their health, such as loneliness, financial distress, transportation issues. Some patients feel overwhelmed by their medical needs and feel like a “burden” on loved ones, and feel no one understands their concerns.

  • The findings are significant in light of other research that finds 80 percent of health outcomes are related to factors outside the traditional realm of healthcare delivery, including social, economic, and behavioral.