Three papers on what a decade of Medicare care-management evidence says about between-visit care — the clinical case, the value-based-care case, and the operational case. Written for the people who run independent primary care.
What CMS's own evaluation found when Medicare paid for structured between-visit care — $74 per patient per month in slower spending growth, driven by fewer hospital and ED services — plus the specific ingredients that separate programs that work from the low-touch ones that failed, and why only 4% of eligible patients ever received it.
Why CMS designed APCM to compound value-based care rather than compete with it: ACO participation automatically satisfies APCM's performance-measurement requirement, APCM billing reinforces beneficiary attribution, and the funded clinical activity maps directly onto the measures ACOs are scored on — with the other side of the ledger addressed honestly.
Why chronic care management stalled at 4 percent of eligible patients — minute-by-minute time logging, consent friction, and a staffing model that needed ~131 enrolled patients to break even on one nurse — and how APCM's per-patient monthly codes, tiered by complexity instead of minutes, change the operating math for independent practices.
The Between-Visit Care Evidence Series · July 2026. Citations to CMS evaluations, federal rulemaking, and the peer-reviewed literature appear in each paper. These papers are for general information and are not billing, legal, or medical advice.