National-level chronic disease management programs: One gap to ruin it all

A review of the current chronic disease management initiatives that reveals the gap that hinders significant improvements and explains how to override it.

National-level chronic disease management programs One gap to ruin it all

While caregivers, insurers and government launch multiple initiatives to support chronic patients day to day, we don't notice any significant improvement in chronic disease management. The situation either stagnates or worsens.

It takes just a brief look at the numbers of complications and death rates to prove that something is clearly wrong with the current CDM. For example, according to the CDC-published statistics, the age-adjusted percentage of people aged 35 years or over with diabetes and with a self-reported heart disease or stroke showed little or no change from 2005 to 2011. Heart disease rates were ranging from 21.6 to 21.9 percent, and stroke from 7.6 to 9.1 percent.

So what is wrong? We came up with a short summary of current CDM-improving efforts around three dimensions of healthcare (policymakers, caregivers and insurers) to answer this question.

Governmental CDM initiatives: CMS, HHS, and AHRQ


CMS focuses on both chronic disease prevention and management.

As for prevention, 10 states (TX, NH, CT, MT, HI, CA, WI, NY, MN and NV) adopted the Medicaid Incentives for the Prevention of Chronic Diseases model. Under this model, the participating state should develop a 3-year or longer program targeting at least one of the prevention goals, such as tobacco cessation, weight control or reduction, blood pressure control, cholesterol lowering and diabetes avoiding (or diabetes management). Such program's costs are reimbursed through grant funds.

The Independence at Home Demonstration model is the ACA-based initiative focusing on chronically ill patients. Under the model, the CMS Innovation Center works with medical practices to deliver primary care services at home and thus to improve health outcomes and reduce costs for Medicare patients with multiple chronic conditions.

CMS awards incentive payments to the caregivers that are effectively improving care delivery while reducing expenditures. According to the recent press release, 46% of participants succeeded in achieving this goal as for 2016.


HHS acknowledges the chronic disease management problem and suggests providers to facilitate self-care activities and thus better engage patients in self-management. It addresses the problem of multiple chronic conditions (MCCs) through a number of federal programs and a special document to support them as a national-level guidance – Multiple Chronic Conditions: A Strategic Framework.


Empowered by the HHS's Strategic Framework, AHRQ has funded the MCC Research Network. This network aims to uplift the research field for multiple chronic conditions, support both clinicians and patients, as well as advise policymakers about effective methods to measure and promote safe, high-quality and coordinated care for multi-chronic patients.

AHRQ also highlights the importance of IT for MCCs, yet these announcements were made back in 2014, and currently there are no activities in this field.

Overview of caregivers' CDM activities

Health systems and large hospitals. We took 20 random caregivers from the list of 100 largest US hospitals. 9 out of 20 providers (45%) offer certain chronic disease management programs to their patients. Only one of 9 caregivers helping chronic patients with a condition-specific program additionally introduces 24 / 7 patient support via a blog.

Community hospitals. The list of 100 great community hospitals helped us to choose 20 random providers for the research. 8 out of 20 caregivers (40%) offer diabetes-related CDM programs to their patients. One of 8 providers proposing such a program also supports patients 24 / 7 by phone.

ACO hospitals / medical centers. We sorted out 20 random caregivers from the list of 272 ACOs. 7 out of 20 providers (35%) offer diabetes-related chronic disease management programs to their patients. However, none of them provides 24 / 7 patient support.

Insurance companies and their initiatives on chronic diseases

Insurers are naturally interested in improving care quality while lowering costs. This motivation can rise even higher among emerging concerns on whether ACA Marketplaces becoming unprofitable for major health insurers. As treating a chronic condition (including MCC) tolls heavy on patients' shoulders, higher premiums along with rising costs on ACA-driven insurance plans can be balanced only with additional benefits for patients with complex conditions.

For this overview, we took 10 biggest players on the health insurance market and evaluated them according to the following criterion.

Chronic disease-focused programs

10 out of 10 insurers (100%) under our consideration support chronic patients with specific programs that come in all shapes and sizes: one-on-one consultations with nurses, phone consultations, home visits, support group meetings and more. The outlined programs don't impose any additional obligations on chronic patients willing to enroll. While all patients with chronic diseases, especially those with MCCs and complex conditions, can enroll, insurers don't guarantee that every enrollee will be included into the program.

To expand their programs and support more chronic patients, insurers may also enable certain technological solutions allowing patients to connect with their physicians, nurses, consultants and social workers remotely. Thus, we were also interested in the number of insurers powering their chronic disease management plans with IT.

Technology in chronic disease-related programs

7 out of 10 companies (70%) additionally back up their chronic care plans and programs with different tech tools: from disease-specific educational emails (30%) to video appointments (10%) and patient-oriented health portals and websites (30%), such as Anthem's MyHealth portal with a personalized and secure message center, calorie counter, health profile, health assessment, fitness management advices and more features.

A common gap in current CDM initiatives

As healthcare is a highly innovative environment, it is rather strange to observe such a low-level technological support of the programs for chronic patients against all three dimensions we reviewed, with the only exception of insurers. In general, current initiatives are insufficient for a full-fledged remote care and guidance, as they lack one essential thing: consistency.

Of course, nurse home visits and face-to-face interactions with a physician are as important as support group meetings, and no technology can substitute the warmth of human support and acceptance. But, even when it can be hard to accept, most of the time a patient faces their disease alone.

If in these hard times a patient is unable to keep up with his or her CDM, it can entail various health risks, such as complications and exacerbations followed by hospitalizations and readmissions.

To reduce these risks, a patient need to feel backed up 24 / 7, not on demand, as in case of emails, calls or blog support, but by default.

Technology enables to improve chronic disease management

This is where a tech-run chronic disease management model can help to meet the need. Potentially, a chronic patient taps into a full-cycle infrastructure, bound to his or her mobile device via a specific disease-centered mHealth app. This app becomes a patient's individual CDM management tool, providing guidance, offering personalized information and serving as a patient's health journal with current vitals, treatment goals and medication information.

Moreover, this app is connected to a provider's CRM system, which allows notifying the care team members on any significant change in their patients' conditions. With this continuous and automatic data interaction, patients don't need to make a call to share with their caregiver the worries on, for example, a higher blood glucose level. When a patient enters this information into the app, the numbers are analyzed and correlated with individually set normal values of blood glucose for this particular patient.

A final word

Caregivers, insurers and policymakers are trying to create the programs and plans that will dramatically improve chronic patients' lives once and for all. But last time we checked (Sept 2016 at CDC ) chronic diseases were still accounting for 86% in the US healthcare budget. So maybe not today, but tomorrow is the moment to make a change to root chronic disease management in technology.

Otherwise, the ambitious trio of reduced costs, elevated care quality and patients' increased health outcomes will just stay a shattered dream within the value-based care environment.

Author's bio:

With 5 years of writing on business and technology, Lola is a Healthcare Industry Analyst at ScienceSoft, a software development and consulting company headquartered in McKinney, Texas. Being an HIMSS member, she focuses on Healthcare IT, highlighting the industry challenges and technology solutions that tackle them. Lola's articles explore chronic disease management, mHealth, healthcare data analytics, value-based care delivery, CMS regulations and more.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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