Chronic medical conditions account for $3 out of
every $4 spent on health care in the United States. Eighty percent of
seniors have at least one chronic condition. And, for the 3.8 million boomers
aging-in to Medicare every year starting in 2011, 60% have a chronic
condition.The “aging of America” means
chronic medical conditions will continue to increase and consume more of our
health care dollars.
Aggressive management of
chronic conditions is critical to every health insurer’s viability, accounting
for over 75% of hospital admissions, over 80% of prescriptions and over 70% of
visits to physicians.Costs associated
with these conditions can quickly ratchet-up a plan’s Medical Loss Ratio to a
point of no-return, unless they can identify these patients using laser-focused,
actionable care management.
Next generation medical
management must be grounded in evidence-based clinical practices, predictive
outcomes modeling, patient engagement, and multidisciplinary professional
collaboration. New payer-provider partnerships can dramatically enhance care coordination,
reduce hospital readmissions, and break new ground by applying information
technology to track the cost and results of managing chronic conditions.
The future of chronic care management is being built
around a patient-centered approach—comprehensive care that is accessible,
continuous, and family-centric, structured around a primary care physician. This
pursuit of “patient centeredness” will result in a partnership among
practitioners, patients, families, and caregivers to ensure that decisions
respect patients’ wants, needs and preferences; and ensure access to education
and support to make decisions and participate in their own care. Patient centeredness
has also given rise to two trends gaining traction: medical home and
accountable care organizations.
Medical home is an approach to providing comprehensive care
that is coordinated across a patient’s healthcare community – hospitals,
specialty physicians, pharmacists, social services, home health, and ancillary
providers. It provides a vision of care for all stages of life, acute and
chronic, wellness and prevention, and end-of-life. In a medical home model a
patient’s engagement in the management of their chronic conditions is improved
along with their overall health care experience.
Accountable Care Organizations, ACOs, are provider-centric
organizations responsible for the cost and quality of care received by a
specific group of patients. Payment incentives (and disincentives) are built-in
so physicians and hospitals are financially “at-risk” to meet quality and cost
targets. ACOs foster management of an entire episode of care in an integrated
patient-centered structure while promoting proactive care planning.
Tomorrow’s medical management cannot just be a reinvention
of utilization management and prior authorization. They need to move the insurer
into a role of facilitating, not limiting, providers. Patients become a central
resource directing communications with the member through the doctor-patient
relationship. It also means supporting clinicians with reliable data,
giving front-line professionals the information and tools to effectively manage
the patient care continuum.
Effective medical management
is one of the few solutions to “bend the
cost curve” and at the same address quality of care. Complex chronic care
needs to be the top priority. The future is integrated medical management that
is patient centered, led by primary care providers and driven by
accountability: consumer engagement, provider quality and health plan
RECOMMENDATION: The Partnership to Fight Chronic Diseaseis a great resource.
PFCD is a national coalition of patient, provider, community, business/labor,
and health policy experts committed to raising awareness of the number one
cause of death, disability, and rising health care costs in the U.S.—chronic