More than a phone call: The hidden value of chronic care management

As the U.S. population ages and chronic conditions increasingly drive healthcare costs, medical practices feel growing pressure to manage patients’ long-term health more effectively without overwhelming staff or sacrificing quality.

Chronic care management (CCM) has become a necessity in specialties managing patients with ongoing or long-term conditions; however, integrating CCM into a value-based care model presents challenges, including time management, billing complexity, stakeholder buy-in, and patient engagement.

At the 2025 MGMA Summit, Julie Mobley, MBA, CMPE, CPC, practice administrator at Cullman Internal Medicine PC in North Alabama and founder of Gemstone Consulting, provided a practical roadmap for CCM implementation in her session, “Bridging Gaps: Chronic Care Management and Value-Based Care.”

Mobley, with more than 20 years of healthcare operations experience, emphasized measurable outcomes. “You cannot change what you cannot measure,” she said, invoking the famous Peter Drucker quote. “I love having data that enables us to pivot quickly when necessary and make decisions based on the data that we find.”

Chronic care management today

Mobley detailed the structural foundations of CCM, including CMS’ definitions and reimbursement mechanisms.

“CMS refers to chronic care management as ‘connected care management,’” she explained. “And that is actually what we have named our program — connected care management.”

That language resonates more positively with patients, focusing on coordination and support rather than chronic conditions alone.

Since Medicare CCM service coverage began in 2015, more commercial payers recognized the value of managing chronic conditions between patient visits. CCM incentivizes continuous coordination, outreach, and monitoring rather than limiting care to the exam room.

To qualify, patients must have at least two chronic conditions expected to last a lifetime and potentially place them at significant risk. Mobley encouraged attendees to “review the comprehensive list because there are things you may not think about,” citing conditions such as HIV, stroke, arthritis, and Alzheimer’s.

Mobley stressed that CCM encompasses more than brief phone interactions. “This is a great way to get paid for work that your staff is already doing,” she said. “They can retrieve the report, get it uploaded into your system, and the time spent on those activities [can be] billable for CCM.”

She added that rural health clinics (RHCs) and federally qualified health centers (FQHCs) are also authorized to receive payment for CCM services, calling the program “a viable and often underutilized tool for improving care access and reimbursement in underserved communities.”