Medicare Chronic Disease Management Vital to Cut Healthcare Costs

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Chronic disease management plans need improvements across the country, but Medicare must lead the way, according to the Partnership to Fight Chronic Disease.

 Effective chronic disease management is imperative in a healthcare industry in which costs are only going up. However, without adequate patient engagement and care coordination strategies, efforts to mitigate chronic care issues will not be successful, leaving the market to handle ever-rising healthcare costs.

Study after study has proven that ineffective chronic disease management has resulted in high healthcare costs. In 2006, AHRQ found that about five percent of the population accounts for over half of overall healthcare spending. Agency research yielded similar results again in 2012 and as recently as 2016.

Priorities to drive successful chronic disease management are generally agreed upon throughout the healthcare industry, but lackluster patient engagement and care coordination plans have left those management programs falling flat, according to Ken Thorpe, the chairman at the Partnership to Fight Chronic Disease.

The US still spends about $3.2 billion on healthcare, Thorpe noted in a recent interview with, and 86 percent of that is tied to chronic disease care.

“Any discussion around cost containment has got to focus on three things,” Thorpe asserted.

“One is to find mechanisms to prevent or slow the growth and the problems across disease,” Thorpe explained. “The second is to do a better job of earlier detection of chronic illness. Third is building delivery systems nationally that really are effective at managing patients with multiple chronic conditions.”

But as it stands, most medical models aren’t doing enough to address those priorities. Few payment models incentivize early detection or even prevention of chronic illness because they do not have adequate payoffs for providers who engage in this level of care.

And if a patient does develop a chronic illness, payment models limit provider ability to coordinate quality care for the patient.

Much of the responsibility to make policy improvements falls on Medicare, said Thorpe, who previously served as the HHS Deputy Assistant Secretary for Health Policy under President Clinton. Because of its longstanding role as a pioneer in the payer space and its breadth of chronically ill patients (52 percent of patients with five or more chronic illnesses have Medicare), Medicare is well-positioned to spur industry-wide change.

This change is urgent, Thorpe added. Currently, Medicare’s chronic disease population accounts for three-quarters of the program’s spending. As estimates for chronic illness growth continue to swell, Medicare faces potential cost growth to $42 trillion come 2030.

But although the Medicare program does have some value-based care models underway, the payer is not doing enough to address this growing problem, Thorpe said. These programs do not reach enough patients, and regardless of whether a patient receives value-based or fee-for-service care, the care coordination and preventive care is inadequate.

Roughly two-thirds of Medicare patients are still in the fee-for-service Medicare program,” Thorpe said. “And there really isn’t any comprehensive care coordination at all in Medicare despite the fact that they have half the patients with five or more chronic healthcare conditions.”

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Medicare’s pitfalls could be credited to lack of leadership buy-in, Thorpe posited. Medicare has also been facing research suggesting its value-based care may not be as powerful as some advocates may say. These reports indicate that although care coordinate and patient access services are valuable, the cost proposition to implement them is not there.

A 2017 study published in Health Affairs suggested that although value-based care programs improved patient access to care, drove care coordination, and reduced emergency department visits, they did not yield the cost savings to cover those management costs.

A separate Health Affairs study showed that Medicare Shared Savings Program (MSSP) participants saw an average care quality score of 93 out of 100 points. However, only about half of participants saw cost savings.

But part of the issue is that Medicare is not building the right programs to prevent and manage chronic illness, Thorpe asserted. If Medicare models used community care teams with nurses, nurse practitioners, pharmacists, and social workers, stakeholders could work together to keep patients healthier.

“If Medicare lead the way there, we’d see broader adoption of team-based, patient-focused care,” Thorpe explained. “There is a lot of good evidence that shows that that actually works to save money and keep patients healthy.”

Current Medicare models don’t do much by way of incentivizing care coordination. There is only one CPT code for care coordination and one for transitional care, which is hindering provider ability to leverage effective team-based care.

In some cases, providers even need to add to patient cost-sharing to deliver on the promise of coordinated, team-based care. About 400,000 patients that participate in care coordination are responsible for about 20 percent of those costs, Thorpe pointed out.

And as high healthcare costs prevent many patients from accessing key healthcare services – specifically preventive care – these models are not advantageous to cost containment.

The healthcare industry is slated to see a continued increase the number of chronically ill patients. As more seniors age into the Medicare population, it will be incumbent for the public payer to identify key chronic disease prevention and care management strategies.

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These strategies need to evolve, Thorpe stated. Although Medicare has begun paving the way for value-based and patient-centered care, it must do more to address the true needs of patients.

“The current route is just not working,” Thorpe concluded. “CMS needs to reevaluate where they are in care coordination and fee-for-service Medicare and if there is some evidence-based models that they could adopt.”

Source: ( By Sara Heath)