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Game Changer: Chronic Condition Care Management

Posted Mar 12 2010 6:43pm

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 collaboration.

RECOMMENDATION: The Partnership to Fight Chronic Disease is 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 disease.


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