Chronic Disease Management

Our current health system presents multiple challenges to the effective and efficient care of chronically ill patients. First, the fragmented nature of our system means patients have multiple care providers who do not consistently communicate with each other, and are not individually or collectively responsible for the totality of patients’ care. Second, healthcare is centered around care in a doctors’ office or hospital, while evidence shows the overwhelming proportion of the care needed by chronically ill patients takes place at home and in the community. Third, our predominant provider payment systems reward high-cost medical interventions over higher-value primary care; they reward volume of care over quality of care. Fourth, the trend toward patients assuming higher burdens of cost sharing (i.e. deductibles and co-pays) in the health insurance market creates disincentives to patient utilization of chronic disease diagnosis and treatment services that contribute to effective disease management and cost control.

The following policy recommendations are designed to reduce costly inefficiencies in delivery of chronic disease care by reducing duplication of services and provision of inappropriate care, and to improve care coordination that leads to better health outcomes:

  1. Establish a public-private National Commission on Chronic Disease Management. The Commission will advise the Secretary of HHS and the appropriate Congressional committees regarding effective strategies to improve coordination and quality of care for the millions of Americans who suffer from chronic conditions. The Commission will identify opportunities for public-private collaboration to improve treatment related to chronic disease, and review and commission health services research to evaluate the effectiveness of alternative approaches to organizing, delivering, and managing evidence-based interventions to support delivery of care that are known to be effective.

  2. Require that within five years, all federallyfunded or supported health programs offer a patient-centered medical home (or similar health care delivery model1) option to every beneficiary.

    The “patient-centered medical home” is emerging as a leading model for efficient management and delivery of quality care (particularly to an increasingly chronically ill U.S. population), because it links multiple points of health delivery by utilizing a team approach with the patient at the center. A report by the Commonwealth Fund estimates that encouraging adoption of medical homes in Medicare would save $175 billion over 10 years.

    An ideal medical home setting emphasizes primary care, utilizes interoperable electronic records to maximize coordination, and involves the patient in decision making to maximize adherence to care plans. A medical home also emphasizes enhanced care through open scheduling, expanded hours and communication between patients, physicians and staff. Some variations broaden the patient-centered medical home model beyond the physician’s office and into the community and the patients’ home.

    The National Committee for Quality Assurance (NCQA) has designed a program to assess how medical practices are functioning as patient-centered medical homes. The program emphasizes the systematic use of patient-centered, coordinated care management processes. The NCQA standards are aligned with the joint principles of the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA), which define the key characteristics of the patient-centered medical home. (Principles are listed in Appendix 1).

    Patients with chronic conditions require additional care management services to avoid progression of their disease and should be encouraged to participate actively in their own care. Comprehensive disease management programs offered within a medical home environment have demonstrated promise to provide individuals with severe/or multiple chronic health conditions with interventions and support appropriately tailored on the seriousness and severity of the patient’s medical condition, patient preferences, and needs. A medical home (or similar health care delivery model) providing care to beneficiaries of federally-funded or supported health programs should assure that patients diagnosed with a chronic disease care can participate in a qualified chronic disease management program.

  3. Align provider and patient incentives to form and join high performance health care delivery organizations and reward compliance with best practice guidelines for prevention and treatment of chronic disease within those organizations.

    Provider Incentives:

    Fee-for-service reimbursements, which incentivize volume over value of services should be changed to a system of reimbursements that incentivize provisions of sets of services that conform to best-practice guidelines established by professional consensus and based on evidence. To advance this objective, we propose the following provider incentives:

    1. Incentivize formation of medical homes by providing medical homes (and similar health care delivery models) a per-member, per-month bonus for each enrolled beneficiary of a federally-funded or supported health program.

    2. Further incentivize formation of Community Health Teams (CHTs) by providing federal grants, or sharing in per-member, per-month bonuses for supporting provision of physician or medical home primary care to beneficiaries of federally-funded or supported health programs.

      A CHT is a team of allied health professionals, including behavioral/mental health specialists, community outreach/ prevention specialists (responsible for linking the patient-centered medical home or primary care practice with communitybased prevention resources), nurse care coordinators (such as nurse practitioners) that provide multidisciplinary care support to primary care practices across a community. Their goal is to provide expertise designed to prevent disease and provide higher quality lower cost health care particularly targeting chronically ill patients. Further information about CHTs can be found in Appendix 2.

    3. Provide bonuses to primary care physicians practicing in medical homes (or similar health care delivery models), who exceed benchmarks for consensus-based quality measures such as a reduction in ER visits, reductions in ambulatory sensitive admissions, reduction in 30-day readmissions, and percentage of patients who receive condition-appropriate medical services such as annual eye exams, HbA1g tests.

    4. Expand Medicare’s hospital quality incentive demonstration program to all hospitals.

      Even as lessons of current demonstration programs are integrated into design of the health care delivery system, expanding this voluntary program to all hospitals – and rewarding hospitals that consistently provide high-quality care based on consensus-based standards - holds promise for developing and improving a quality-based hospital payment system. It would also provide important incentives for hospitals to improve the quality of care they provide to their patients.

    5. Allow providers to share in the financial savings associated with better care through formation of regional Accountable Care Networks.

      In our current health care system, medical providers often operate in silos with no one provider responsible for a patient’s medical outcome.

    6. Providers that form regional Accountable Care Networks should be eligible for gain-sharing bonus payments if they 1) reduce the per capita growth in federallyfunded or supported health insurance plan spending in their region, 2) they reduce hospital readmission rates , and 3) show continued improvement in clinical preventive treatments for chronically ill patients (i.e. annual eye exams, HbA1g tests).

      Accountable Care Networks – a formal regional grouping of medical providers in which physicians (multispecialty), hospitals, medical homes, CHTs and other care providers are linked together and provide team-based care that includes coordination of transitions between patient care settings – hold promise for helping to promote more accountability improving care quality and controlling wasteful spending. The above-listed incentives encourage members of the Accountable Care Network to coordinate to fulfill this promise.

    Patient Incentives:

    The patient-centered medical home has demonstrated promise for significantly improving efficient management and delivery of quality care, particularly to an increasingly chronically ill U.S. population. In order to encourage beneficiaries of federally-funded or supported health programs to elect care of this quality, we propose the following patient incentives:

    1. Waive all cost-sharing for all recommended preventive and clinically-recommended chronic disease management services for federally-funded or supported health program beneficiaries who opt to receive care through a patient-centered medical home (or similar health care delivery model).

    2. Discount premiums for beneficiaries of federally-funded or supported health program who are diagnosed with chronic disease and elect to enroll in a qualified medical home chronic disease management program. Continuation of the premium discount would depend on ongoing patient compliance with his/her care plan.

  4. Strengthen the primary care workforce

    Transforming chronic disease management in the health care system requires a new emphasis on primary care and depends on the availability of a robust primary care workforce, including physicians, nurses, social workers, care managers, dietitians, pharmacists, occupational therapists, and other allied health professionals. Investments aimed at increasing our primary care workforce are crucial to make care coordination through the medical home and disease management programs a reality. Therefore, we recommend:

    1. Increase payments to primary care providers in federally-funded or supported health programs.

    2. Expand loan forgiveness and tuition assistance programs that encourage potential primary care practitioners to enter the field (e.g. retiring a portion of medical and nursing school debt per year of service as primary care physicians and allied health providers, subsidizing continuing education of nurses to become nurse educators).

Endnotes

  1. A “similar health care delivery model” refers to a small primary care practice that contracts with a Community Health Team or “CHT” for supplemental support needed to qualify, at a minimum, for NCQA classification as a Level I medical home. (See “Community Health Team” defined in Recommendation #3.b of this section.)

Our current health system presents multiple challenges to the effective and efficient care of chronically ill patients. First, the fragmented nature of our system means patients have multiple care providers who do not consistently communicate with each other, and are not individually or collectively responsible for the totality of patients’ care. Second, healthcare is centered around care in a doctors’ office or hospital, while evidence shows the overwhelming proportion of the care needed by chronically ill patients takes place at home and in the community. Third, our predominant provider payment systems reward high-cost medical interventions over higher-value primary care; they reward volume of care over quality of care. Fourth, the trend toward patients assuming higher burdens of cost sharing (i.e. deductibles and co-pays) in the health insurance market creates disincentives to patient utilization of chronic disease diagnosis and treatment services that contribute to effective disease management and cost control.

The following policy recommendations are designed to reduce costly inefficiencies in delivery of chronic disease care by reducing duplication of services and provision of inappropriate care, and to improve care coordination that leads to better health outcomes:

  1. Establish a public-private National Commission on Chronic Disease Management. The Commission will advise the Secretary of HHS and the appropriate Congressional committees regarding effective strategies to improve coordination and quality of care for the millions of Americans who suffer from chronic conditions. The Commission will identify opportunities for public-private collaboration to improve treatment related to chronic disease, and review and commission health services research to evaluate the effectiveness of alternative approaches to organizing, delivering, and managing evidence-based interventions to support delivery of care that are known to be effective.

  2. Require that within five years, all federallyfunded or supported health programs offer a patient-centered medical home (or similar health care delivery model1) option to every beneficiary.

    The “patient-centered medical home” is emerging as a leading model for efficient management and delivery of quality care (particularly to an increasingly chronically ill U.S. population), because it links multiple points of health delivery by utilizing a team approach with the patient at the center. A report by the Commonwealth Fund estimates that encouraging adoption of medical homes in Medicare would save $175 billion over 10 years.

    An ideal medical home setting emphasizes primary care, utilizes interoperable electronic records to maximize coordination, and involves the patient in decision making to maximize adherence to care plans. A medical home also emphasizes enhanced care through open scheduling, expanded hours and communication between patients, physicians and staff. Some variations broaden the patient-centered medical home model beyond the physician’s office and into the community and the patients’ home.

    The National Committee for Quality Assurance (NCQA) has designed a program to assess how medical practices are functioning as patient-centered medical homes. The program emphasizes the systematic use of patient-centered, coordinated care management processes. The NCQA standards are aligned with the joint principles of the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP) and the American Osteopathic Association (AOA), which define the key characteristics of the patient-centered medical home. (Principles are listed in Appendix 1).

    Patients with chronic conditions require additional care management services to avoid progression of their disease and should be encouraged to participate actively in their own care. Comprehensive disease management programs offered within a medical home environment have demonstrated promise to provide individuals with severe/or multiple chronic health conditions with interventions and support appropriately tailored on the seriousness and severity of the patient’s medical condition, patient preferences, and needs. A medical home (or similar health care delivery model) providing care to beneficiaries of federally-funded or supported health programs should assure that patients diagnosed with a chronic disease care can participate in a qualified chronic disease management program.

  3. Align provider and patient incentives to form and join high performance health care delivery organizations and reward compliance with best practice guidelines for prevention and treatment of chronic disease within those organizations.

    Provider Incentives:

    Fee-for-service reimbursements, which incentivize volume over value of services should be changed to a system of reimbursements that incentivize provisions of sets of services that conform to best-practice guidelines established by professional consensus and based on evidence. To advance this objective, we propose the following provider incentives:

    1. Incentivize formation of medical homes by providing medical homes (and similar health care delivery models) a per-member, per-month bonus for each enrolled beneficiary of a federally-funded or supported health program.

    2. Further incentivize formation of Community Health Teams (CHTs) by providing federal grants, or sharing in per-member, per-month bonuses for supporting provision of physician or medical home primary care to beneficiaries of federally-funded or supported health programs.

      A CHT is a team of allied health professionals, including behavioral/mental health specialists, community outreach/ prevention specialists (responsible for linking the patient-centered medical home or primary care practice with communitybased prevention resources), nurse care coordinators (such as nurse practitioners) that provide multidisciplinary care support to primary care practices across a community. Their goal is to provide expertise designed to prevent disease and provide higher quality lower cost health care particularly targeting chronically ill patients. Further information about CHTs can be found in Appendix 2.

    3. Provide bonuses to primary care physicians practicing in medical homes (or similar health care delivery models), who exceed benchmarks for consensus-based quality measures such as a reduction in ER visits, reductions in ambulatory sensitive admissions, reduction in 30-day readmissions, and percentage of patients who receive condition-appropriate medical services such as annual eye exams, HbA1g tests.

    4. Expand Medicare’s hospital quality incentive demonstration program to all hospitals.

      Even as lessons of current demonstration programs are integrated into design of the health care delivery system, expanding this voluntary program to all hospitals – and rewarding hospitals that consistently provide high-quality care based on consensus-based standards - holds promise for developing and improving a quality-based hospital payment system. It would also provide important incentives for hospitals to improve the quality of care they provide to their patients.

    5. Allow providers to share in the financial savings associated with better care through formation of regional Accountable Care Networks.

      In our current health care system, medical providers often operate in silos with no one provider responsible for a patient’s medical outcome.

    6. Providers that form regional Accountable Care Networks should be eligible for gain-sharing bonus payments if they 1) reduce the per capita growth in federallyfunded or supported health insurance plan spending in their region, 2) they reduce hospital readmission rates , and 3) show continued improvement in clinical preventive treatments for chronically ill patients (i.e. annual eye exams, HbA1g tests).

      Accountable Care Networks – a formal regional grouping of medical providers in which physicians (multispecialty), hospitals, medical homes, CHTs and other care providers are linked together and provide team-based care that includes coordination of transitions between patient care settings – hold promise for helping to promote more accountability improving care quality and controlling wasteful spending. The above-listed incentives encourage members of the Accountable Care Network to coordinate to fulfill this promise.

    Patient Incentives:

    The patient-centered medical home has demonstrated promise for significantly improving efficient management and delivery of quality care, particularly to an increasingly chronically ill U.S. population. In order to encourage beneficiaries of federally-funded or supported health programs to elect care of this quality, we propose the following patient incentives:

    1. Waive all cost-sharing for all recommended preventive and clinically-recommended chronic disease management services for federally-funded or supported health program beneficiaries who opt to receive care through a patient-centered medical home (or similar health care delivery model).

    2. Discount premiums for beneficiaries of federally-funded or supported health program who are diagnosed with chronic disease and elect to enroll in a qualified medical home chronic disease management program. Continuation of the premium discount would depend on ongoing patient compliance with his/her care plan.

  4. Strengthen the primary care workforce

    Transforming chronic disease management in the health care system requires a new emphasis on primary care and depends on the availability of a robust primary care workforce, including physicians, nurses, social workers, care managers, dietitians, pharmacists, occupational therapists, and other allied health professionals. Investments aimed at increasing our primary care workforce are crucial to make care coordination through the medical home and disease management programs a reality. Therefore, we recommend:

    1. Increase payments to primary care providers in federally-funded or supported health programs.

    2. Expand loan forgiveness and tuition assistance programs that encourage potential primary care practitioners to enter the field (e.g. retiring a portion of medical and nursing school debt per year of service as primary care physicians and allied health providers, subsidizing continuing education of nurses to become nurse educators).

Endnotes

  1. A “similar health care delivery model” refers to a small primary care practice that contracts with a Community Health Team or “CHT” for supplemental support needed to qualify, at a minimum, for NCQA classification as a Level I medical home. (See “Community Health Team” defined in Recommendation #3.b of this section.)

Contents

Chronic Disease Management & Coordination of Care

Follow Us On:

 

Follow Us On: