By Phil Galewitz and Holly K . Hacker KFF Health News

Carrie Lester looks forward to the phone call every Thursday from her doctors ’ medical assistant , who asks how she ’ s doing and if she needs prescription refills . The assistant counsels her on dealing with anxiety and her other health issues .

Lester credits the chats for keeping her out of the hospital and reducing the need for clinic visits to manage chronic conditions including depression , fibromyalgia , and hypertension .

“ Just knowing someone is going to check on me is comforting ,” said Lester , 73 , who lives with her dogs , Sophie and Dolly , in Independence , Kansas .

At least two-thirds of Medicare enrollees have two or more chronic health conditions , federal data shows . That makes them eligible for a federal program that , since 2015 ,

has rewarded doctors for doing more to manage their health outside office visits .

But while early research found the service , called Chronic Care Management , reduced emergency room and in-patient hospital visits and lowered total health spending , uptake has been sluggish .

Federal data from 2019 shows just 4 % of potentially eligible enrollees participated in the program , a figure that appears to have held steady through 2023 , according to a Mathematica analysis . About 12,000 physicians billed Medicare under the CCM mantle in 2021 , according to the latest Medicare data analyzed by KFF Health News .

By comparison , federal data shows about 1 million providers participate in Medicare .

Even as the strategy has largely failed to live up to its potential , thousands of physicians have boosted their annual pay by participating , and auxiliary

for-profit businesses have sprung up to help doctors take advantage of the program . The federal data showed about 4,500 physicians received at least $ 100,000 each in CCM pay in 2021 .

Through the CCM program , Medicare pays to develop a patient care plan , coordinate treatment with specialists , and regularly check in with beneficiaries . Medicare pays doctors a monthly average of $ 62 per patient , for 20 minutes of work with each , according to companies in the business .

Without the program , providers often have little incentive to spend time coordinating care because they can ’ t bill Medicare for such services .

Health policy experts say a host of factors limit participation in the program . Chief among them is that it requires both doctors and patients to opt in . Doctors may not have the capacity to regularly monitor

patients outside office visits . Some also worry about meeting the strict Medicare documentation requirements for reimbursement and are reluctant to ask patients to join a program that may require a monthly copayment if they don ’ t have a supplemental policy .

“ This program had potential to have a big impact ,” said Kenneth Thorpe , an Emory University health policy expert on chronic diseases . “ But I knew it was never going to work from the start because it was put together wrong .”

He said most doctors ’ offices are not set up for monitoring patients at home . “ This is very time-intensive and not something physicians are used to doing or have time to do ,” Thorpe said .

For patients , the CCM program is intended to expand the type of care offered in traditional , feefor-service Medicare to match benefits that — at