Original Research20 October 2015
A Modeling Study
    Author, Article, and Disclosure Information



    Physicians have traditionally been reimbursed for face-to-face visits. A new non–visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015.


    To estimate financial implications of CCM payment for primary care practices.


    Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements.

    Data Sources:

    National Ambulatory Medical Care Survey and other published sources.

    Target Population:

    Medicare patients.

    Time Horizon:

    10 years.




    Comparison of CCM delivery approaches by staff and physicians.

    Outcome Measures:

    Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services.

    Results of Base-Case Analysis:

    If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 000 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services.

    Results of Sensitivity Analysis:

    If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time.


    The CCM program may alter long-term primary care use, which is difficult to predict.


    Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs.

    Primary Funding Source:



    • 1. Song ZRose SSafran DGLandon BEDay MPChernew MEChanges in health care spending and quality 4 years into global payment. N Engl J Med2014;371:1704-14. [PMID: 25354104] doi:10.1056/NEJMsa1404026 CrossrefMedlineGoogle Scholar
    • 2. Lewis VAColla CHCarluzzo KLKler SEFisher ESAccountable care organizations in the United States: market and demographic factors associated with formation. Health Serv Res2013;48:1840-58. [PMID: 24117222] doi:10.1111/1475-6773.12102 CrossrefMedlineGoogle Scholar
    • 3. Epstein AMJha AKOrav EJLiebman DLAudet AMZezza MAet alAnalysis of early accountable care organizations defines patient, structural, cost, and quality-of-care characteristics. Health Aff (Millwood)2014;33:95-102. [PMID: 24395940] doi:10.1377/hlthaff.2013.1063 CrossrefMedlineGoogle Scholar
    • 4. Song ZLandon BEControlling health care spending—the Massachusetts experiment. N Engl J Med2012;366:1560-1. [PMID: 22494111] doi:10.1056/NEJMp1201261 CrossrefMedlineGoogle Scholar
    • 5. Landon BEKeeping score under a global payment system. N Engl J Med2012;366:393-5. [PMID: 22296073] doi:10.1056/NEJMp1112637 CrossrefMedlineGoogle Scholar
    • 6. Landon BEStructuring payments to patient-centered medical homes. JAMA2014;312:1633-4. [PMID: 25335142] doi:10.1001/jama.2014.9529 CrossrefMedlineGoogle Scholar
    • 7. McWilliams JMLandon BEChernew MEZaslavsky AMChanges in patients' experiences in Medicare accountable care organizations. N Engl J Med2014;371:1715-24. [PMID: 25354105] doi:10.1056/NEJMsa1406552 CrossrefMedlineGoogle Scholar
    • 8. Centers for Medicare & Medicaid Services. Policy and payment changes to the Medicare Physician Fee Schedule for 2015. Baltimore: Centers for Medicare & Medicaid Services; 2014. Accessed at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-31-7.html on 11 November 2014. Google Scholar
    • 9. Centers for Medicare & Medicaid ServicesChronic Care Management Services Fact Sheet. Baltimore: Centers for Medicare & Medicaid Services; 2015. Google Scholar
    • 10. Basu SLandon BESong ZBitton APhillips RSImplications of workforce and financing changes for primary care practice utilization, revenue, and cost: a generalizable mathematical model for practice management. Med Care2015;53:125-32. [PMID: 25517074] doi:10.1097/MLR.0000000000000278 CrossrefMedlineGoogle Scholar
    • 11. Husereau DDrummond MPetrou SCarswell CMoher DGreenberg Det alCHEERS Task ForceConsolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BJOG2013;120:765-70. [PMID: 23565948] doi:10.1111/1471-0528.12241 CrossrefMedlineGoogle Scholar
    • 12. Medical Group Management Association. DataDive. Englewood, CO: Medical Group Management Association; 2015. Accessed at http://data.mgma.com/datadive/rdPage.aspx on 24 August 2015. Google Scholar
    • 13. IBM. IBM Kenexa CompAnalyst Market Data for US on Cloud. Armonk, NY: IBM; 2015. Accessed at www-03.ibm.com/software/products/en/ibm-kenexa-companalyst-market-data-for-us-on-cloud on 24 August 2015. Google Scholar
    • 14. Centers for Disease Control and PreventionNational Ambulatory Medical Care Survey (NAMCS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Google Scholar
    • 15. Centers for Medicare & Medicaid Services (CMS), HHSMedicare program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. Final rule with comment period. Fed Regist2014;79:67547-8010. [PMID: 25507411] MedlineGoogle Scholar
    • 16. Centers for Medicare & Medicaid ServicesAnnual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS). Baltimore: Centers for Medicare & Medicaid Services; 2011. Google Scholar
    • 17. Bureau of Labor StatisticsConsumer Price Index. Washington, DC: Bureau of Labor Statistics; 2015. Google Scholar
    • 18. Basu SAndrews JComplexity in mathematical models of public health policies: a guide for consumers of models. PLoS Med2013;10:e1001540. [PMID: 24204214] doi:10.1371/journal.pmed.1001540 CrossrefMedlineGoogle Scholar
    • 19. Medical Group Management AssociationCost Survey for Single-Specialty Practices. Englewood, CO: Medical Group Management Association; 2014. Google Scholar
    • 20. American Academy of Family Physicians. FPM Series: The Direct Observation of Primary Care Study. Leawood, KS: American Academy of Family Physicians; 2014. Accessed at www.aafp.org/journals/fpm/explore/topic/dopcs.html on 3 November 2014. Google Scholar
    • 21. Design Cost Data. NHBC Database. Valrico, FL: Design Cost Data; 2007. Accessed at www.d4cost.net/dcd/session/new on 24 August 2015. Google Scholar
    • 22. Patel MSArron MJSinsky TAGreen EHBaker DWBowen JLet alEstimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care2013;19:509-16. [PMID: 23844711] MedlineGoogle Scholar
    • 23. U.S. Census BureauCurrent Population Survey: Annual Social and Economic Supplements. Washington, DC: U.S. Census Bureau; 2013. Google Scholar
    • 24. Centers for Medicare & Medicaid ServicesMedicaid Moving Forward 2014. Baltimore: Centers for Medicare & Medicaid Services; 2014. Google Scholar
    • 25. Agency for Healthcare Research and QualityMedical Expenditure Panel Survey. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Google Scholar
    • 26. Cuenca AEMaking Medicare annual wellness visits work in practice. Fam Pract Manag2012;19:11-6. [PMID: 22991904] MedlineGoogle Scholar
    • 27. Bureau of Labor StatisticsOccupational Outlook Handbook. Washington, DC: Bureau of Labor Statistics; 2014. Google Scholar
    • 28. Schillinger DBibbins-Domingo KVranizan KBacchetti PLuce JMBindman ABEffects of primary care coordination on public hospital patients. J Gen Intern Med2000;15:329-36. [PMID: 10840268] CrossrefMedlineGoogle Scholar
    • 29. Ferguson JAWeinberger MCase management programs in primary care. J Gen Intern Med1998;13:123-6. [PMID: 9502373] CrossrefMedlineGoogle Scholar
    • 30. Grumbach KThe patient-centered medical home is not a pill: implications for evaluating primary care reforms. JAMA Intern Med2013;173:1913-4. [PMID: 24018538] doi:10.1001/jamainternmed.2013.7652 CrossrefMedlineGoogle Scholar
    • 31. Christensen EWDorrance KARamchandani SLynch SWhitmore CCBorsky AEet alImpact of a patient-centered medical home on access, quality, and cost. Mil Med2013;178:135-41. [PMID: 23495457] CrossrefMedlineGoogle Scholar
    • 32. Bielaszka-DuVernay CVermont's Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood)2011;30:383-6. [PMID: 21383346] doi:10.1377/hlthaff.2011.0169 CrossrefMedlineGoogle Scholar
    • 33. Coleman KReid RJJohnson EHsu CRoss TRFishman Pet alImplications of reassigning patients for the medical home: a case study. Ann Fam Med2010;8:493-8. [PMID: 21060118] doi:10.1370/afm.1190 CrossrefMedlineGoogle Scholar
    • 34. DeVries ALi CHSridhar GHummel JRBreidbart SBarron JJImpact of medical homes on quality, healthcare utilization, and costs. Am J Manag Care2012;18:534-44. [PMID: 23009304] MedlineGoogle Scholar
    • 35. Driscoll DLHiratsuka VJohnston JMNorman SReilly KMShaw Jet alProcess and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation. Ann Fam Med2013;11 Suppl 1:S41-9. [PMID: 23690385] doi:10.1370/afm.1474 CrossrefMedlineGoogle Scholar
    • 36. Fillmore HDuBard CARitter GAJackson CTHealth care savings with the patient-centered medical home: Community Care of North Carolina's experience. Popul Health Manag2014;17:141-8. [PMID: 24053757] doi:10.1089/pop.2013.0055 CrossrefMedlineGoogle Scholar
    • 37. Flottemesch TJAnderson LHSolberg LIFontaine PAsche SEPatient-centered medical home cost reductions limited to complex patients. Am J Manag Care2012;18:677-86. [PMID: 23198711] MedlineGoogle Scholar
    • 38. Friedberg MWSchneider ECRosenthal MBVolpp KGWerner RMAssociation between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA2014;311:815-25. [PMID: 24570245] doi:10.1001/jama.2014.353 CrossrefMedlineGoogle Scholar
    • 39. Gilfillan RJTomcavage JRosenthal MBDavis DEGraham JRoy JAet alValue and the medical home: effects of transformed primary care. Am J Manag Care2010;16:607-14. [PMID: 20712394] MedlineGoogle Scholar
    • 40. Harbrecht MGLatts LMColorado's Patient-Centered Medical Home Pilot met numerous obstacles, yet saw results such as reduced hospital admissions. Health Aff (Millwood)2012;31:2010-7. [PMID: 22949450] doi:10.1377/hlthaff.2012.0359 CrossrefMedlineGoogle Scholar
    • 41. Maeng DDGraham JGraf TRLiberman JNDermes NBTomcavage Jet alReducing long-term cost by transforming primary care: evidence from Geisinger's medical home model. Am J Manag Care2012;18:149-55. [PMID: 22435908] MedlineGoogle Scholar
    • 42. Milstein AGilbertson EAmerican medical home runs. Health Aff (Millwood)2009;28:1317-26. [PMID: 19738247] doi:10.1377/hlthaff.28.5.1317 CrossrefMedlineGoogle Scholar
    • 43. Phillips RLBronnikov SPetterson SCifuentes MTeevan BDodoo Met alCase study of a primary care-based accountable care system approach to medical home transformation. J Ambul Care Manage2011;34:67-77. [PMID: 21160354] doi:10.1097/JAC.0b013e3181ffc342 CrossrefMedlineGoogle Scholar
    • 44. Raskas RSLatts LMHummel JRWenners DLevine HNussbaum SREarly results show WellPoint's patient-centered medical home pilots have met some goals for costs, utilization, and quality. Health Aff (Millwood)2012;31:2002-9. [PMID: 22949449] doi:10.1377/hlthaff.2012.0364 CrossrefMedlineGoogle Scholar
    • 45. Reid RJJohnson EAHsu CEhrlich KColeman KTrescott Cet alSpreading a medical home redesign: effects on emergency department use and hospital admissions. Ann Fam Med2013;11 Suppl 1:S19-26. [PMID: 23690382] doi:10.1370/afm.1476 CrossrefMedlineGoogle Scholar
    • 46. Roby DHPourat NPirritano MJVrungos SMDajee HCastillo Det alImpact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system. Med Care Res Rev2010;67:412-30. [PMID: 20519430] doi:10.1177/1077558710368682 CrossrefMedlineGoogle Scholar
    • 47. Rosenberg CNPeele PKeyser DMcAnallen SHolder DResults from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption of the model. Health Aff (Millwood)2012;31:2423-31. [PMID: 23129672] doi:10.1377/hlthaff.2011.1002 CrossrefMedlineGoogle Scholar
    • 48. Steiner BDDenham ACAshkin ENewton WPWroth TDobson LACommunity Care of North Carolina: improving care through community health networks. Ann Fam Med2008;6:361-7. [PMID: 18626037] doi:10.1370/afm.866 CrossrefMedlineGoogle Scholar
    • 49. Takach MReinventing Medicaid: state innovations to qualify and pay for patient-centered medical homes show promising results. Health Aff (Millwood)2011;30:1325-34. [PMID: 21734207] doi:10.1377/hlthaff.2011.0170 CrossrefMedlineGoogle Scholar
    • 50. Mathematica Policy ResearchEvaluation of the Comprehensive Primary Care Initiative: First Annual Report. Princeton: Mathematica Policy Research; 2015. Google Scholar
    • 51. Moore KJChronic care management and other new CPT codes. Fam Pract Manag2015;22:7-12. [PMID: 25591226] MedlineGoogle Scholar
    • 52. Caro JJBriggs AHSiebert UKuntz KMISPOR-SMDM Modeling Good Research Practices Task ForceModeling good research practices—overview: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force-1. Med Decis Making2012;32:667-77. [PMID: 22990082] CrossrefMedlineGoogle Scholar
    • 53. Hofert MMächler MNested Archimedean copulas meet R: the nacopula package. J Stat Softw2011;39:1-20. CrossrefGoogle Scholar
    • 54. Taha HAOperations Research: An Introduction. 9th ed. Upper Saddle River, NJ: Prentice Hall; 2010. Google Scholar
    • 55. Siegel JEWeinstein MCRussell LBGold MRRecommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine. JAMA1996;276:1339-41. [PMID: 8861994] CrossrefMedlineGoogle Scholar