Top Chronic Care Management Companies in 2025

I. Why CCM Companies Matter in 2025

Chronic care management is no longer a side initiative. For many hospitals and startups, it has become a core pillar of value-based care strategy. Market estimates place the CCM industry’s value at $1.7 to $6.7 billion in 2024, with projections ranging from $6 billion to $27 billion by 2030. CMS reimbursement expansion, demographic pressures, and the push toward accountable primary care models fuel this growth.

Hospitals are caught between two realities. On one hand, the financial upside of CCM is clear, with reimbursements ranging from $60 to $130 per patient per month, depending on complexity. On the other hand, care teams face administrative overload, staff shortages, and interoperability challenges with Epic and other EHRs.

Mid-market hospitals are increasingly turning to outsourcing, with 60 to 80% preferring vendors that manage billing, patient enrollment, and care coordination at a large scale. Meanwhile, digital health startups are entering the CCM market with agility. They bring API-first builds, wearable integrations, and AI-driven tools that offer a sharper edge in engagement and risk prediction.

This blog maps out the landscape of CCM companies, examines how startups are carving out space, highlights the market gaps that remain, and positions Mindbowser as the technology partner for hospitals and Series B+ startups that want to build CCM platforms of the future.

II. Landscape of CCM Companies (Tier 1 and Tier 2)

A. Tier 1 Full-Service Vendors

The CCM market is anchored by Tier 1 vendors that offer comprehensive, full-service solutions. These companies specialize in virtual nursing, enrollment, and compliance documentation. Providers such as ChartSpan, Signallamp, and CareHarmony are well-known names in this segment. They deploy care coordinators who work directly within EHRs, often reducing the burden on hospital staff who would otherwise be tasked with outreach, consent management, and compliance reporting.

Tier 1 vendors also integrate basic predictive analytics and care pathways. For example, HealthSnap combines CCM with remote patient monitoring, creating bundled service offerings that are attractive to Medicare-focused organizations. Welldoc, with its FDA-cleared diabetes platform, represents a narrower clinical focus but demonstrates how digital therapeutics can extend into CCM billing streams. KangarooHealth emphasizes multilingual support and rapid deployment, which aligns with the needs of hospitals serving diverse populations.

The strength of Tier 1 vendors lies in scale and predictability. Hospitals choose them for stability, especially when compliance audits are top of mind. However, these platforms often rely on standardized workflows that may not adapt quickly to niche patient populations or value-based contracts with unique risk-sharing terms.

B. Tier 2 and Emerging Players

Tier 2 companies offer SaaS-first models that provide CCM software without requiring a large nursing staff infrastructure. Mahalo Health, Athelas, and CoachCare operate in this space, giving providers the option to run CCM in-house while leveraging software for alerts, documentation, and billing capture. These platforms often emphasize device integration, enabling physicians to track vitals in real-time across patient cohorts.

Emerging players also experiment with bundling CCM into broader telehealth platforms. Some focus on behavioral health, while others expand into post-COVID rehab or chronic rehabilitation management. This reflects a growing demand for niche CCM solutions that extend beyond general chronic conditions and into specialty care.

The limitation of Tier 2 vendors is their lighter connection to payers and limited use of AI. Without predictive modeling or advanced audit preparation, their solutions risk falling short in value-based contracts. This gap opens the door for startups that bring workflows such as CarePlan AI to the table, directly addressing payer concerns around cost reduction and readmission risk.

III. How Startups Differentiate: Agility and Niche Focus

Startups entering the chronic care management space have an advantage in speed and focus. Unlike Tier 1 vendors, which rely on standardized workflows and established infrastructure, startups can move quickly to address niche populations, specialty conditions, and gaps in interoperability. Their agility lies in three key areas: technology, clinical specialization, and revenue models.

A. API-First and Wearable Integration

Startups typically build CCM solutions with an API-first design. This allows rapid integration with Epic, Cerner, Athenahealth, and mid-tier EHRs, which are often closed or fragmented for larger vendors. They also bring built-in support for wearable ecosystems, connecting data streams from Fitbit, Garmin, Dexcom, and Apple HealthKit. By enabling providers to visualize patient vitals in real time, startups improve adherence and reduce clinical blind spots.

B. Specialty-Driven CCM Models

Another way startups differentiate is by targeting specific patient populations. Some focus exclusively on behavioral health, building CCM platforms that integrate social services, housing, and transportation coordination. Others concentrate on cardiac and pulmonary rehabilitation, where adherence to prescribed programs directly affects reimbursement.

One startup has built a rehabilitation app with real-time heart monitoring that helps patients stay within safe zones, while also providing clinicians with structured data for compliance reporting.

Another developed a platform that automates financial assistance workflows by integrating directly with electronic health records via FHIR APIs, reducing manual entry by 90% and accelerating patient approvals.

By addressing the social and financial determinants that affect chronic care, these startups create differentiated value for both providers and payers.

C. Revenue Models and Scalability

Startups also experiment with revenue models that differ from the fixed-fee or license-based structures of Tier 1 vendors. Revenue-sharing agreements, payer-aligned contracts, and white-label solutions have gained traction, especially among Series B+ companies aiming to expand nationally. This flexibility makes it easier for hospitals and health systems to adopt without the upfront capital burdens of $50,000 to $1 million per year, which are typical for larger vendors.

A behavioral health initiative demonstrated the flexibility of this model by building value-based networks with hospitals, payers, and social services. The approach resulted in a 52% reduction in readmissions and a 12.1% decrease in Medicaid costs. Startups can replicate this playbook by combining interoperability, niche expertise, and payer partnership.

D. Role of workflows in Startup Success

The use of workflows further sharpens startup differentiation. CarePlan AI has been shown to reduce care coordination delays by 42%, providing startups with a measurable edge in scaling patient throughput without compromising compliance. Similarly, AI Readmission Risk predicts which patients are most likely to be readmitted within 30 days, allowing providers to intervene earlier and avoid costly penalties. These workflows allow startups to compete head-to-head with Tier 1 vendors by demonstrating clear ROI to CFOs and payer partners.

Related read: Chronic Care Management Companies in 2026: How to Choose the Right Partner for Outcomes and ROI

IV. Market Gaps: AI, SDOH, Epic Integration

Even with strong growth in chronic care management, the market remains far from mature. Providers and payers continue to identify structural gaps that neither Tier 1 vendors nor smaller SaaS platforms have fully addressed. These gaps are shaping the next phase of competition and partnership in CCM.

A. Limited Use of AI in CCM Platforms

Artificial intelligence has been widely promoted across healthcare, but most CCM platforms still use it in a limited way. Current applications often stop at basic risk stratification or reminders. What is missing is AI that builds audit-ready packets, predicts readmissions, or automatically adjusts care plans based on patient history.

B. Gaps in SDOH Integration

Social determinants of health are well known to affect outcomes, but most CCM companies only capture clinical data. Without access to housing, food security, or behavioral health information, providers cannot design comprehensive care plans. This creates blind spots that lead to increased readmissions and emergency visits.

One initiative shows how SDOH integration can change the equation. By embedding surveys on environmental conditions, socioeconomic factors, and substance use, and combining them with demographic and vital sign data, providers were able to reduce ER visits by 67%. Despite results like these, most CCM platforms still lack structured tools for SDOH, leaving room for new entrants to differentiate themselves.

C. Epic-Centric Interoperability Challenges

Epic remains the dominant EHR in mid-market hospitals, but it is also one of the most closed systems. While some Tier 1 vendors have developed custom Epic integrations, many startups face steep barriers. The result is fragmented workflows, where CCM data sits outside the EHR or requires manual entry.

FHIR-native, API-first integrations are the solution, but adoption is uneven. Connectivity with platforms like Epic via FHIR and HL7 has already proven that financial eligibility workflows can be automated, cutting manual entry by 90%. The same logic applies to CCM, where automated data pulls can save thousands of staff hours annually. Until interoperability becomes standard, Epic integration will remain a critical gap and a defining factor for which companies succeed.

V. Why Startups Choose Mindbowser: API-First, White-Label, and ROI-Ready Solutions

Startups often face the same barriers as hospitals: integration headaches, compliance risk, and the need to prove ROI to payers. What differentiates successful digital health companies is not only speed of innovation but also the ability to scale in a way that is audit-ready, payer-aligned, and technically sound. This is where Mindbowser positions itself as the build partner of choice.

A. API-First and FHIR-Native Engineering

Mindbowser has invested in API-first and FHIR-native architectures that integrate with Epic, Cerner, Athenahealth, Healthie, and Canvas. These builds give startups immediate interoperability and eliminate manual workarounds that create compliance gaps. Instead of waiting months for integration projects, startups can deploy with ready-to-use pipelines that connect directly into EHR workflows.

B. White-Label CCM Platforms for Growth

For Series B+ startups scaling nationally, time to market is critical. Mindbowser delivers white-label CCM platforms that can be customized, branded, and adapted to each company’s unique business model. This allows founders to focus on growth and payer contracts while relying on a proven engineering foundation.

C. Deploying Proven Workflows

Mindbowser incorporates workflows into client builds to create measurable ROI. CarePlan AI is used to streamline patient discharge and reduce coordination delays by 42%. AI Readmission Risk enables proactive intervention by flagging patients most likely to be readmitted within 30 days. Together, these capabilities help startups present a stronger case to payers and CFOs who are demanding proof of cost reduction and outcome improvement.

Realted read: Building a Chronic Care Management Program: A 2025 Playbook for Hospitals and Digital Health Leaders

VI. How Mindbowser Can Help

Mindbowser positions itself as both a technology partner and a compliance ally for hospitals and startups navigating the complexities of chronic care management. The value lies not only in building software but in creating audit-ready systems that integrate seamlessly with existing workflows.

End-to-End Build Partner

Mindbowser supports organizations from concept through scale. This includes product strategy, UX design for patient and provider apps, EHR interoperability, remote patient monitoring, and automated billing workflows. Every build is designed to meet CMS and HIPAA requirements, reducing compliance risk while accelerating adoption.

ROI-Driven Outcomes

Hospitals and startups are under pressure to justify every investment they make. Mindbowser backs projects with a clear ROI framework. Case outcomes show reductions in documentation time, faster care coordination, and measurable drops in readmission rates.

Strategic Fit for Both Hospitals and Startups

Mid-market hospitals often look for outsourcing models that reduce staff burden while maintaining compliance. Startups need scalable, white-label solutions that can attract payer contracts and investors. Mindbowser delivers on both fronts by combining deep engineering expertise with compliance-first workflows.