As CMS continues pushing providers toward value-based care models, innovative technologies are emerging to address the workforce shortage and scaling challenges. Could AI voice agents be the missing piece your practice needs?
Healthcare systems nationwide face an unprecedented challenge: with 60% of Americans managing at least one chronic condition—driving nearly $1 trillion in annual healthcare costs—the traditional care delivery model is buckling under pressure.
The statistics are sobering:
This reality has made Chronic Care Management (CCM) programs essential for healthcare systems transitioning to value-based care (VBC) models. Yet implementing effective CCM faces a fundamental obstacle: chronic care isn't scalable today because clinics lack the workforce, time, and systems to engage patients consistently between visits.
Consider the all-too-common patient journey of someone like Layla, a 55-year-old who works from home and has become increasingly inactive since the pandemic:
"This scenario plays out thousands of times daily across America," explains Matteo Grassi, CEO of Hana AI, a company developing AI voice agents for chronic care management. "The system isn't designed to catch patients who fall through the cracks between scheduled visits."
Grassi discovered this challenge firsthand after initially exploring mental health applications. "Mental health had more resistance and less immediate need. Primary care had bigger challenges but easier adoption paths," he notes, explaining his company's pivot to focus on chronic care solutions.
Traditional CCM programs rely heavily on human staff making phone calls, sending reminders, and managing care plans—tasks that are time-consuming and difficult to scale. AI voice technology is changing this paradigm in several key ways:
"One of the biggest challenges in patient engagement is technology adoption," says Drew Kearney, Chief Strategy Officer at Signallamp Health. "Many chronically ill patients, particularly elderly ones, struggle with apps and patient portals."
AI voice agents like Hana's system offer a frictionless alternative, conducting phone-based check-ins that require no app downloads, passwords, or technical skills from patients. The familiar experience of answering a phone call removes barriers to engagement.
AI-powered systems continuously monitor patient responses for warning signs, applying sophisticated algorithms to detect subtle changes in reported symptoms, medication adherence, or behavioral patterns.
"Our system can detect when a diabetic patient reports increased thirst, fatigue, and headaches, immediately flagging them for provider follow-up before these symptoms lead to an emergency," explains Grassi. "This early intervention capability is transforming how we manage chronic conditions."
Every chronic disease patient has unique needs, challenges, and preferences. AI systems can personalize support based on individual patient data, adjusting communication frequency, education content, and intervention strategies.
These systems learn from patient interactions, continuously refining their approach to drive better engagement and outcomes—something impossible to achieve manually at scale.
With staff shortages affecting healthcare nationwide, efficiency is paramount. AI voice agents act as intelligent filters, handling routine check-ins and only escalating issues requiring clinical judgment.
"A clinic with 2,500 patients can effectively manage 715 additional chronic cases, adding $400K in revenue annually without expanding staff," notes Grassi. "The technology dramatically extends the reach of existing care teams."
Medicare's CCM reimbursement requirements include detailed documentation and minimum time thresholds. AI systems automatically track all interactions, ensuring complete documentation for billing purposes.
By automating CPT coding and ensuring proper documentation, these systems help practices capture the full $65-110 per patient monthly reimbursement they're entitled to receive.
The foundation of effective chronic care is a trusted relationship between patients and their care team. AI voice agents extend this relationship through regular, personalized communication that reinforces the connection to the provider.
"Patients don't see the AI as replacing their doctor," explains Grassi. "They experience it as an extension of their provider's care—always available, consistently attentive, and directly connected to their healthcare team."
AI systems generate rich data about patient populations, identifying trends, gaps in care, and opportunities for intervention at both individual and population levels.
These insights help practices prioritize resources, adjust care protocols, and demonstrate quality metrics required for value-based care success.
For practices considering AI voice agents to enhance their CCM programs, the implementation process typically follows three steps:
"The technology essentially removes the administrative burden that prevents many practices from implementing successful CCM programs," says Grassi. "Clinicians focus on clinical decision-making while the AI handles patient outreach, documentation, and routine follow-up."
As healthcare continues its shift toward value-based payment models, AI-powered care coordination is poised to become the standard approach to chronic disease management.
Current trends suggest three phases of adoption:
"The next wave of innovation isn't about replacing humans—it's about amplifying them to make everyday tasks simpler, faster, and more effective," explains Grassi. "In healthcare, this means letting providers focus on what they do best—diagnosing complex conditions and developing treatment plans—while AI handles consistent monitoring and engagement."
For healthcare organizations looking to thrive in value-based care environments, implementing an AI-enhanced CCM program offers compelling advantages:
The transition to value-based care presents challenges but also unprecedented opportunities for practices willing to embrace innovative care delivery models. By combining human clinical expertise with AI-powered engagement systems, providers can simultaneously improve patient care while strengthening their financial position in this evolving landscape.
Want to learn more about implementing AI-enhanced chronic care management? Read our related articles:
Have you implemented AI technology in your CCM program? Share your experiences in the comments below!
