Synergy: Chronic Care Management & Value Based Care

Value-Based Care vs Fee-for-Service

The American healthcare landscape is seeing a gradual shift away from fee-for-service (FFS) as a way to deliver healthcare. Value Based Care (VBC) is more than a trend now, it is  a strategy that all physicians and hospitals submitting claims for MEDICARE patients will be required to adopt by 2030.

Value-Based Care: Quality Measures

In FFS, claims are submitted for reimbursement with each physician-patient encounter. VBC focuses on the quality of those visits and whether it leads to desirable outcomes over the quantity of visits. Medicare sets forth quality measures that must be met before a provider gets reimbursed. In the last decade, the number of patients receiving Value Based Care has increased by 20.3 million patients according to a 2023 report from insurer Humana. Within this group, there have been 30.1% fewer hospitalizations compared to those on original Medicare plans.

Value-Based Care: Cost Savings

Value-Based Care cuts down on overutilization of services and redundancy in diagnostics leading to decreased administrative costs. The same study as above saw 23.2% in cost savings compared to Medicare, averaging $527 in annual savings per patient

Value-Based Care and Chronic Care Management.

Value-Based Care’s healthcare delivery model is the proposed vehicle for Medicare’s longstanding efforts to improve quality. Chronic Care Management (CCM) operates as the machinery for that vehicle. Less than half of all primary care physicians in the U.S. are a part of Value Based Care programs and only 5% of eligible Medicare recipients are enrolled in a Chronic Care Management program. 

CCM’s cornerstones are continued management of chronic conditions and proactive measures to keep patients out of the ER and routed to their Primary Care Physicians for care. Reimbursed for work done in 20 minute increments in a month, Medicare has increased payments for the most commonly submitted CPT code for this service from $40 to $63. Time spent, even if it is only 20 minutes, on connecting the dots to make navigating the healthcare landscape simpler for patients, can pay off multiple folds in accomplishing the goals set forth by Medicare.

Let’s follow patient John through his healthcare journey with CCM in place.

John is 74 years old with a history of Hypertension and Diabetes Mellitus II. He receives a call from his CCM nurse Susie at least once every month where she through direct interrogation and indirect cues determines the status of his health. In the friendly exchange, he reports to her his compliance with his meds and his guilt about the extra slices of cake that he indulged in during his grandson’s birthday party.

Nurse Susie motivates him to continue adherence to his medication regimen and not let the slices of cake derail his progress.

She educates him about frequent blood glucose checks and increased water consumption.

– She informs him about the to-dos for blood glucose elevations that stay persistently elevated; one being to notify Nurse Susie so that she can escalate it to his Primary Care doctor.

– Nurse Susie makes a notation in the CCM software that puts John at the top of her list to contact daily until she is assured that his blood glucose elevations have resolved. This encounter was approximately 14 minutes, which is just 3 minutes shy of the average time spent by a physician in the exam room with a patient. The yield of this exchange empowers John with interventions he needs in that moment of time, a follow-up plan, and a safety net in Nurse Susie… all by just answering a call.

Quality Measures

1. Reduce Hospital Readmissions

It is estimated that $25 to $45 billion is spent on complications and hospital readmissions¹ which could be prevented with sufficient coordination of care transitions. The University of Texas Medical Branch (UTMB) implemented a program that included effective transition of care, improved patient education, clinician accountability, and communication breakdown fixes. ² An all-encompassing care coordination program powered by analytics led to a 14.% relative reduction in the 30-day all-cause readmission rate and $1.9 million in cost savings.³

Let’s revisit our patient John. Nurse Susie calls him 48 hours later and learns that his blood glucose has been in the 200s for the last 24 hours agnostic of meals. She conducts a cursory triage to rule out any concerning symptoms and contacts the PCP’s clinic and secures a “walk-in” telemedicine visit with one of the Physician Assistants. She notifies John about the appointment and even sends him a reminder an hour leading up to it. This prevents John from making a panicked ER visit and continues care with his PCP.

2. Enhanced Patient Communication

Woodside Medical in Southeast Arkansas implemented a Chronic Care Management program with a goal to establish a direct connection between its patients and healthcare team to better understand the impediments in the healthcare journey of chronically ill patients. Its use of ChronicCareIQ as its software partner allowed the staff nurses to “become a reassuring point of contact for patients, guiding them through treatments and […] improved communication positively impacts patient satisfaction. 

Innate to CCM is the path to accomplish the dual goal of reduced hospital admission and increased cost savings… The quantifiable improvements in outcomes are a testimony to Medicare’s push towards value-based care as the way forward to modern medicine.


CCM Nurse Susie

Hello John! How are you feeling today?


 I’m doing better now that I talked to that PA. Thank you for setting that up.

CCM Nurse Susie

 No problem! I see that she ordered some labs. 


Yes! My daughter will come pick me up tomorrow. We will get some breakfast and then she will take me to get me labs.

CCM Nurse Susie

John, you have to be fasting for those labs. You know that right?


Oh now I do! Ok so we will go to breakfast after.

Chronic care management stands as a cornerstone in the evolution towards value-based care, emphasizing patient-centered approaches and long-term health outcomes. By focusing on coordinated care, proactive health management, and the integration of technology, healthcare providers can deliver more effective, personalized treatment plans that not only improve the quality of life for patients with chronic conditions but also reduce overall healthcare costs. The shift to value-based care is not without its challenges, but the potential benefits in terms of patient satisfaction and system sustainability make it a crucial direction for the future of healthcare. Embracing this paradigm shift requires commitment and innovation, but the reward is a healthier, more resilient population that enjoys better healthcare experiences and outcomes.


  1. Health Affairs Health Policy Brief. (2012). Improving care transitions.
        Retrieved from: 0120913.327236&format=full
  3. The Joint Commission. (2012). Transitions of care: The need for a more effective approach to continuing patient care.
        Retrieved from:


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