The provider community strives day and night to improve patient outcomes and contribute to the dream of value-based healthcare. However, the complexity of chronic diseases renders strategies ineffective and prevents them from reducing available utilization. In the US, chronic diseases account for 75 percent of all healthcare spending, to the tune of $3.5 trillion. In fact, every 6 out of 10 US adults is living with a chronic condition.

And, the costs are going to inflate in the future as well

 By 2030, there will be more than 77 million+ people above 65 that necessitates Medicare coverage, which also calls for better chronic care management measures. If high-risk populations are identified now, the US healthcare can be better prepared to meet care expectations in the future and contain the costs for good. That said, a myopic approach to chronic care isn’t going to cut it. Let’s take a look at the loopholes in current chronic care management programs.

Pitfalls in Chronic Care Management

 Fixation on short term goals

Effective chronic care management requires providers to focus on long-term well-being and stabilization needs of patients. However, the Affordable Care Act incentivizes providers for a reduction in 30-day readmissions post-discharge. To witness a visible and landslide impact in chronic care management, providers must be looking for a mechanism that can track care management for high-risk patients beyond the 30-day readmission policy.

Less accommodation for comorbidities

Multiple chronic conditions have associated comorbidity that can increase the costs in the long run. Healthcare needs to inch to a robust system that takes into account the needs of comorbid patients. Mckinsey research suggests that 71% of patients with heart failure have hypertension, 37% have diabetes, and 53% have hyperlipidemia. These stats indicate that providers have the opportunity to go upstream and engage with these patients while they have a low-morbidity condition.

Inadequate risk stratification

Risk stratification is majorly centered on the needs of high-risk patients and often negates rising-risk patients. While preventive mechanisms for “high-risk” and “rising-risk” patients require a demarcation, specialty care and telehealth don’t promise a similar ROI for both patient pools. Aside from this, additional factors such as Social Determinants of Health are not an integral part of every risk stratification algorithm that results in skewed chronic care management plans.

Fragmented care delivery

A lack of coordination renders chronic care management ineffective and many a time, patients end up receiving clashing treatments that can lead to increased costs.

Primary care Vs. specialty care

Primary care providers often face a hard time figuring out when a patient can be successfully managed in a primary care setting or qualifies to be under specialty care. Taking the right call between the two often becomes the reason for higher costs because of an increase in acute care utilization.

How Can Providers Conquer these Obstacles?

 Patient identification analytics

For chronic care management to yield desired results, providers must be mining for patients who are most likely to have lifetime care needs while they receive acute care. For instance, in a traditional healthcare setting, patients rush to a healthcare provider for treating a chronic condition.

Patient identification should be such that providers can make an informed decision whether a patient receiving primary care would become a chronic care subject or not. For instance, a person receiving treatment for joint pain can become a candidate for joint replacement, or someone with an advancing kidney disorder could soon require a kidney replacement.

Condition-based care

Interdisciplinary coordination is a prerequisite for effective chronic care management; however, it stretches beyond episodic care. This requires the creation of patient personas to factor future risks, habits, and behavioral patterns to ensure patients adequately engage in their care journey and through a close network of providers, equipment, and ambulatory services; care is not far away from the patient.

Payment models in chronic care management

Although Medicare introduced a reimbursement code for chronic care management in 2015, a leading survey shows that only 51 percent primary care providers are aware they can be paid monthly for non-face-to-face visits for patients living with chronic conditions. The survey also suggests that a vast majority of physicians are yet to introduce chronic care management because of the complexity of reimbursement codes, the amount of paperwork or inadequate incentives.

How data activation can permanently resolve the problem?

Once risk stratification takes place, and people at high risk of developing chronic conditions in general or through a co-morbidity are identified, providers can offer specialized, preventive care mechanisms before a problem becomes a chronic ailment, attracting higher costs and efforts. Apart from taking care of high-risk populations, providers can also prompt healthy communities to go for regular preventive screenings and help them with healthy lifestyle choices.

The road ahead

Technology has been disrupting healthcare in the past and can strengthen chronic care management programs as well. While the focus for most providers lie on compliance, taking a step ahead and having a dual focus on high-risk patients and healthy people can bring a landslide difference to chronic care programs. Care gaps, if any, needs to be closed and addressed in real-time while patient reporting on care journey has to be spot on.


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Abhinav Shashank is the CEO and co-founder of Innovaccer, a leading San Francisco based healthcare technology company. He built the foundation for Innovaccer’s success as a leader in population health management and machine learning-oriented healthcare solutions recognized by Gartner, KLAS, Forbes, Black Book Market Research, and others. Abhinav’s continued efforts and ambition enabled the company to flourish in health information technology in the U.S. and acquire over 25 healthcare organizations as customers, with more than 25,000 providers using Innovaccer’s solutions daily. His continued work and focused approach have resulted in the latest round of Series C investment led by Dragoneer, Tiger, Steadview Capital and M12, Microsoft’s venture fund. With his vision for seamless care delivery using unified patient records, Abhinav is now leading the team towards $1 billion in savings for U.S. healthcare. Additionally, Abhinav Shashank is an influential thought leader and a renowned author. Abhinav has published over 300 articles for various international media outlets, was bestowed a coveted spot in Forbes “30 Under 30 Asia 2017: Enterprise Tech” and was recognized by Becker's Hospital Review as one of the ‘Top 60 rising leaders in U.S. healthcare under 40’ in 2019.

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