6 Ways to Enhance Chronic Care Management for Medicare & Medicare Advantage Populations

Improve Health Outcomes, Drive Member Engagement, and Reduce Costs

Complex and chronic conditions are commonplace among Medicare populations, and one of the most expensive drivers of healthcare spending.

In 2017, an estimated 66 percent of all non-dual-eligible Medicare beneficiaries were living with two or more chronic conditions. In 2020, data from the Chronic Conditions Data Warehouse (CCW) found that 31,860,990 Medicare beneficiaries had a chronic condition.

Annually, chronic conditions are multibillion-dollar expenditures. For example, in 2017, heart disease and strokes cost the U.S. $363 billion per year, diabetes: $327 billion, and arthritis: $304 billion. Each was split between direct medical costs and related productivity and/or care management losses.

study published by the Centers for Medicare and Medicaid Services (CMS) found the following about members with chronic conditions in relation to costs.

  • Healthcare costs and out-of-pocket payments increase with chronic conditions
  • The more chronic conditions a person has, the higher their healthcare costs tend to be
  • Medicare beneficiaries with chronic conditions had significantly more provider visits, hospital admissions or days/nights in a hospital, and higher prescription medication costs and usage

And with 21 qualifying chronic conditions including asthma, heart failure, diabetes, osteoporosis, chronic kidney disease, hypertension, cancer, and Alzheimer’s to name a few, (many of which are just a consequence of age), improving the health outcomes of members who need chronic care management can seem like an overwhelming and costly challenge for both Medicare and Medicare Advantage payers and providers.

This has encouraged CMS, Medicare plans, and providers to shift to value-based care models that focus on prevention, wrapping services around people before they get so sick that their cost of care becomes less burdensome to the member and to the system.

Here are six strategies that can help payers and providers put this into practice, ultimately delivering better health outcomes for members and reducing costs:

1. Prioritize Preventive, Whole-person Care

Take a proactive approach to member health by addressing the whole person. Some ways to do this with Medicare members include:

  • Ensure members schedule (and show up for) their annual physical and their Medicare Annual Wellness Visit (AWV), as well as their Medicare Initial Preventive Physical Examination (IPPE) – also known as the Welcome to Medicare Visit. This exam looks at the whole picture of a member’s health and is used to create a personalized care plan that care teams can use as a starting point for the year and evolve as a member’s health changes throughout the year.
  • Ensure timely performance of assessments and screeningsto identify members at risk for developing or worsening chronic conditions.
  • Connect with members via telemedicine toolsto discuss and adjust care plans, check in on member’s well-being, enact preventive health measures to reduce preventable hospitalizations, decrease the risk for injury or decline (such as falls, medication non-adherence, etc.) and identify/address issues that may be creating obstacles to accessing care or negatively impacting the member’s health.  (CMS expanded the coverage of telemedicine resources for chronic care management following the COVID-19 pandemic, identifying at-home and telehealth visits as key solutions for caring for this population. One that has enabled care teams to continue now at a more efficient pace.)

2. Engage Members in Their Own Health and Wellness

Providing education and guidance to members is a good first step. Engaging people to actively participate in their own healthcare is the end goal. The following approaches can help Medicare and Medicare Advantage payers and providers drive higher member engagement.

  • Encourage care team members to use motivational interviewing,a collaborative and goal-oriented style of communication, that recognizes patients as the best experts in their own care.
  • Consider integrating remote patient monitoring (RPM) devicesinto plan incentive programs. RPM technology allows members to track and monitor health indicators like weight, activity level, heart rate, blood pressure, and blood sugar at home, transmitting data instantly to clinicians. RPM has been shown to not only engage patients in their own care, but also to promote faster, more effective interventions by care teams. CCM and RPM work together to extend quality care and help care teams build closer relationships with patients. Incorporating RPM in CCM can also significantly improve a person’s quality of life and reduce potential adverse events. (For example, HELIOS can process RPM data and flag a care team member when a patient may be at risk for an episode).
  • Provide members with written or video educational materials and resourcesto help them understand their conditions and promote self-management. This may include PDFs, flyers, or articles that encourage adherence to medications and treatment plans or help them learn more about their condition, how to take care of themselves, what red flags to watch out for, and other key information that promotes self-advocacy.

3. Connect Members with Community-Based Resources That Support Health-Related Social Needs

Care management teams need a deep knowledge of community resources like food pantries, transportation, and financial services that are available to members. After all, how can an individual with heart disease follow a recommended diet without access to adequate nutrition? How can someone show up for provider appointments if they don’t have a reliable ride?

Supporting Social Determinants of Health (SDOH) go hand-in-hand with engagement. People who are facing immediate food or financial insecurity are not likely focused on preventive healthcare.

See how Community Care of North Carolina worked to treat social determinants of health as key factors in members’ chronic disease management.

4. Integrate Behavioral Healthcare

Behavioral and mental health support is an important component of whole-person care, as well as chronic disease prevention and management. Address behavioral health needs by leveraging patient health questionnaires, behavioral health-focused care plans, and virtual check-ins.

If feasible, include behavioral health professionals such as a Licensed Clinical Social Worker (LCSW) on staff rather than referring members out, where they may experience access issues or long wait times.  With an LCSW on staff, the care team can more easily ensure immediate access and facilitate a smooth transition for members. And, if a member has transportation issues, they don’t have to work to find a ride to another office on another day to see yet another provider.

5. Enable Better Communication and Collaboration Among the Entire Care Team

As much as possible, eliminate communication bottlenecks and information silos so that everyone involved in a person’s care has a complete view of all aspects of their health. Care coordination among providers, pharmacies, and facilities is key to chronic care management.

For example, coordinate care with pharmacies by linking patients to enhanced pharmacy services such as adherence coaching, daily dose multi-medication blister packaging, and home delivery. This helps ensure patients get refills on time and adds another member to the care team to reinforce understanding of changes to medications, medical conditions, or the plan of care.

Efficient, seamless communication enables better care coordination, collaboration, and sharing of valuable perspectives that inform whole-person care. It also gives providers time back to focus on building relationships with patients.

6. Leverage Medicare CCM 

Providers don’t always have enough time and resources to adequately address the prevention and management of chronic conditions. Layering on additional CCM services functions as a safety net, giving members extra help with prevention and self-management – and CMS recognizes the value of this approach with its Medicare CCM benefit.

The goal of CCM is to provide continuity of care and address medical, functional, and psychosocial needs in order to keep patients safe and healthy at home, or wherever they call home. By design, CCM improves access to care, increases patient engagement and satisfaction, and decreases long-term medical complications, which reduces the overall cost of care.

Under this Medicare Part B benefit, providers can use specific CPT codes to reimburse for CCM services offered outside providers’ office visits. Services must be documented and meet requirements regarding patient eligibility, clinical staff time, personalized care planning, and 24/7 access to health professionals for urgent care needs, among others.

The bottom line? To improve the health outcomes of members with chronic conditions while reducing costs, payers and providers need to focus on strategies that enable care teams to deliver proactive and effective care. 

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