May 21, 2024 2:03:46 PM | 5 Min Read

Chronic Care Management for Physicians and Patients

Chronic Care Management for Physicians and Patients

In 2015 the Centers for Medicare Services created a program for Chronic Care Management (CCM) that has been shown to lower total health spending, reduce emergency room visits, and increase reimbursement for primary care physicians going above and beyond to manage their patients chronic conditions outside of regular office visits. 

Nearly two-thirds of Medicare beneficiaries have two or more chronic conditions that would qualify them for this program, but federal data from 2019 shows that only 4% of potentially eligible members were participating in a CCM program. 

It turns out that very few eligible doctors are participating in the program despite a significant financial incentive to do so, and as a physician myself, I can understand why.

While there are many companies who will assist physicians in launching a CCM program to benefit their patients, few are able to serve the needs of the doctors leading to stagnation and eventual loss of the revenue. 

CCM can be fraught with administrative tasks including compliance, documentation, and hiring and training additional staff to meet with the patients regularly. Most staff can barely keep up with the demands of their current assignments, let alone find additional time to meet with patients weekly to ensure they are staying up to date with their health goals. 

For CCM to be scalable and sustainable it needs to meet the needs of the physicians and their patients. Here are some ways we have seen CCM make a positive impact in the lives of both individuals.

For Patients

It’s a known fact that CCM improves the quality of life for patients who are enrolled in the program. Patients consistently report improved access to healthcare and a better understanding of how their chronic diseases impact their lives. They are happy that someone from the healthcare system is taking an active role in ensuring they have the knowledge and tools they need to experience better health. 


An experienced health coach, such as the ones we employ at ViTel Health, can do more than just check in with patients and help them stay consistent in taking their medications. They help patients set SMART goals around nutrition, movement, substance use, sleep, and even social interactions. In a country plagued by an “epidemic of loneliness” these interactions go a long way towards improving the lives of patients, as well as their health. 

The health coaches are also able to help patients connect with the care they need when they need it. Rather than going to the Emergency Room when they have a concern, a patient can connect with the coach who can relay the concern to the doctor, or even help them schedule an in-person or telehealth visit. A win for patients and for doctors in a capitated arrangement with insurers.

For Physicians

A study conducted by Mathematica found that physician respondents were overall unhappy with the companies claiming to provide outsourced CCM work. “Third-party companies out there turn this into a racket,” stated one doctor. Physicians feel this way because most companies don’t understand them or their patients. They feel that the patients feel bothered rather than supported and this resistance can turn into a headache for them. 

At ViTel Health this is far from the case. We ensure that patients and physicians feel supported at every step of the CCM service from personalized onboarding to regular follow-up to learn about patients as individuals rather than disease states.

Up front costs including hiring and training staff, EMR integrations, and documentation time can all become burdensome for a practice. This limits the number of patients a practice is able to enroll into a program and makes the service unsustainable. 

Working with a company like ViTel Health removes much of this barrier to entry. While some practices may balk at paying a company to perform the work, ViTel Health ensures that all compliance, documentation, data security, integrations, and patient care are connected seamlessly with your existing practice workflows making the cost well worth the effort saved. 

Still on the fence?

Having an experienced and empathic professional to work with when launching a CCM program can be a boon for physicians and their patients. Our team works hard to ensure that patients understand the program, receive benefit from the care, and know that they are important to us and to you their physician. 

As a physician, I know it can be difficult to delegate the care of patients to an outsider, or even a member of your own staff. ViTel Health is your trusted partner in ensuring that your patients with chronic diseases live their best lives, while your practice is able to thrive.

Contact us to learn more!

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