How CCM Helps Drive Success in VBC Contracts: At-Risk vs. Capitated Models

Value-based care (VBC) is no longer just a buzzword; it’s the future of healthcare reimbursement. As the Centers for Medicare & Medicaid Services (CMS) aggressively pushes value-based payment models, provider organizations must deliver better outcomes but also more efficient resource utilization. 

That’s where chronic care management (CCM) becomes a linchpin, especially for managing risk under at-risk or capitated VBC contracts. CCM is a practical option that fits organizations of all sizes and types. 

In this blog, we examine how CCM drives success in value-based contracts by enhancing care coordination, reducing unnecessary costs, and closing data gaps that other models often overlook.

The Landscape of VBC: At-Risk and Capitated Models

Before diving into CCM’s impact, it’s essential to understand the two major VBC contract types:

1. At-Risk Contracts

In these models, providers are accountable for the cost and quality of care, but they continue to bill for services rendered. Organizations benefit from shared savings, or risk losses if they exceed benchmarks. This is common in ACOs or Medicare Shared Savings Programs (MSSP) that carry two-sided risk.

2. Capitated Contracts

Here, providers receive a fixed per-member-per-month (PMPM) payment to cover a patient’s care. This approach emphasizes the predictability of cost but requires tight operational efficiency, since providers assume full financial responsibility for patient outcomes.

In both models, preventing avoidable hospitalizations and emergency department visits is critical, and that’s exactly where CCM excels.

The CMS Mandate: Why VBC Matters Now

Value-based care has been around in some form since the 1980s, beginning with the introduction of managed care. What’s different now? CMS has drawn a line in the sand: Over 50% of Medicare beneficiaries are now tied to value-based contracts as of 2025. That percentage is expected to continue rising.

Healthcare organizations that can’t adapt to this shift risk falling behind financially and clinically. 

And the challenge organizations are left with? Building the right infrastructure to succeed in a system that rewards prevention and coordination, not volume.

CCM’s Role in Value-Based Care Success

Why Does CCM Make VBC Work?

When value-based care fails, it’s rarely because the model is flawed—it’s because organizations chase buzzwords like AI or predictive analytics while neglecting patients’ day-to-day needs. 

Instead, success in VBC hinges on what Jeremy Floyd, a veteran CCM strategist, calls “basic blocking and tackling.” 

Practical CCM Strategies That Improve Outcomes

What does “blocking and tackling” look like in practice?

It means consistently delivering:

• Quarterly PCP visits for chronic disease patients
• Annual wellness visits
• Preventive screenings
• Medication reconciliation
• Social determinants of health (SDOH) support

Chronic care management integrates directly into this foundation. It adds affordable, high-impact touchpoints between office visits to manage chronic conditions more effectively and support population health management goals.

From Theory to Practice: How CCM Impacts Outcomes

Let’s look at what happens on the ground:

• Medication Adherence: A comprehensive “med rec”—short for Medication Reconciliation  — is one of the first steps CCM nurses tackle. This process prevents medication errors, clarifies affordability issues, and addresses misunderstandings that often lead to hospitalizations. Studies show improved adherence alone can reduce inpatient utilization by 10–20%.
• Early Intervention: A nurse triaging a routine CCM call may catch early signs of cellulitis or heart failure. This can lead to a same-day office visit instead of a costly hospitalization—something a claims dashboard would never flag.
• Closing Care Gaps: CCM helps patients schedule and complete preventative screenings, lab work, and specialist referrals. This improves quality scores, a direct factor in reimbursement for ACOs and MSSPs.
• Social Determinants of Health (SDOH): From arranging transportation to enrolling patients in medication assistance programs, CCM nurses bridge gaps that claims data and predictive models can’t see.
  
  

Claims Data Alone Won’t Cut It—Here’s Why

Many organizations rely solely on claims-based risk stratification to determine which patients to enroll in CCM. But claims data is 60–90 days old and misses critical real-time red flags like:

• Changes in patient mobility or caregiver support
• Prescription affordability
• Dietary or food insecurity challenges
• Social isolation or emotional health concerns

By the time claims data reveals a problem, it’s often too late. CCM brings live, human intelligence back into healthcare—a phone call uncovers what a risk score can’t.

Common Mistakes: Why Most CCM Programs Underperform

One of the biggest errors ACOs make is limiting CCM enrollment to just the top 5% “sickest” patients. While understandable from a budget perspective, this is short-sighted for several reasons:

1. The 5% isn’t static—patients move in and out of risk categories.
2. Delayed claims mean delayed insights. You could be acting on outdated info.
3. Undiagnosed or unengaged patients stay invisible.  If they’re not getting services, they don’t appear “risky” on paper.

A better approach? Targeted enrollment guided by claims data with clinical intuition, plus an understanding that spending more on primary care saves on inpatient costs later.

Quality and Coordination: The ACO’s Secret Weapons

In a value-based model like MSSP, shared savings aren’t just tied to reduced costs—they also depend on performance against quality measures. CCM helps close these gaps by:

• Supporting preventive screenings (mammograms, colonoscopies)
• Performing assessments (fall risk, depression screening)
• Improving coding accuracy through better documentation
• Keeping care in-network through preferred referrals

In short, CCM isn’t just about “checking boxes.” Done right, it improves the patient experience and the organization’s bottom line.

Chronic Care Management in Capitated vs. At-Risk Models

While CCM benefits both contract types, the implementation must match the payment structure.

In At-Risk Models:

• Providers can still bill for CCM while managing downside risk.
• There’s a temptation to limit enrollment due to fear of exceeding benchmarks.
• But the added cost of CCM is often outweighed by reductions in ED visits and hospitalizations.

In Capitated Models:

• The fixed payment makes every dollar count.
• CCM offers a cost-effective way to spread resources across a larger population without sacrificing touchpoints.
• It supports predictability—something critical to succeeding under capitation.

CMS supports advanced primary care through mechanisms like prospective capitation with quality-linked reconciliation. Chronic care management aligns directly with this vision by emphasizing prevention and longitudinal care.

Read more on CMS’s view of capitation here →

Conclusion: Why CCM Is a Must-Have for VBC

If you’re managing at-risk or capitated contracts and not fully leveraging CCM, you’re missing one of the most effective tools available to you. From medication adherence to care coordination, CCM delivers real outcomes, builds relationships, and fills critical gaps that data alone can’t.

It's not a flashy tech fix. But in a world of complex incentives and high stakes, simple, patient-centered care is often the most powerful strategy.

Ready to scale a high-performing CCM program for your value-based contract? Book a meeting with our team today to learn how we can help you design and manage a CCM model that fits your population, risk structure, and clinical workflows—without the guesswork.