Utilization of Medicare's chronic care management services by primary care providers

Published:December 30, 2022DOI:


      • Less than 4% of providers billed chronic care management (CCM) services, 2015-2018.
      • Increasing adoption of CCM reflects practice-level investment in team-based care.
      • NPs/PAs represented 47% of providers, but only 15% of CCM billing providers.
      • Large patient panels with high risk scores, primary care services predicted CCM use.
      • Medicare CCM policies should address NP/PA billing and scope of practice barriers.



      Medicare billing codes introduced in 2015 reimburses primary care providers for non-face-to-face, chronic care management (CCM) services rendered by clinical staff.


      The purpose of this manuscript was to describe provider trends in billed CCM services and identify factors associated with CCM utilization.


      Observational study using Medicare Public Use Files, 2015 to 2018. General, family, geriatric, and internal medicine physicians, nurse practitioners (NPs), and physician assistants (PAs) with billed primary care services were included. Multivariable analyses modeled associations between the CCM services and type of provider, adjusting for year, primary care services, practice, and patient characteristics.


      Among 140,465 physicians and 141,118 NPs/PAs, CCM services increased each year, yet remained underutilized: 2% to 7% of physicians and 0.3% to 1.3% of NPs/PAs billed CCM in 2018. Increases in beneficiaries (p < .0001), percentage of dually enrolled (p = .0134), and primary care services (p < .0001) predicted higher CCM utilization.


      CCM utilization reflects practice-based efforts to improve patient access to care by enhancing care delivery.


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