Chronic care management facing uphill battle

Thanks in part to the growing prevalence of chronic disease among American adults, more and more commercial health plans are introducing chronic care management programs. However, the effectiveness of these programs has been hindered by limited patient engagement and the reluctance of doctors to change the way they practice, according to a recent study.

The study, published in The American Journal of Managed Care examined the chronic care management programs of 25 health plans with commercial enrollment of 50,000 or more members. It found similarities in the overall structure of the programs, but differences in the way plans identified members who might need chronic care management, as well as how they matched interventions and resources to patients’ needs and risks.

Nearly half (42%) of the plans studied reported “substantial challenges” to recruiting members to use chronic care management services. Challenges included missing or invalid contact information or members simply not responding to attempts to reach them.

Among members who do participate in a chronic care management program, the most common obstacles to improving care are limited patient engagement (cited by 83% of plans), health literacy (67%) and patient readiness to change (58%). In response, nearly half of the plans report using some form of incentive-such as gift cared, or lowering cost-sharing requirements or premiums-to get patients more engaged.

On the provider side, 67% of the plans cited limited provider staff resources and lack of patient registries and electronic health records as barriers to effective chronic care management. In addition, 63% said that “provider reluctance to change” hampered efforts at better chronic care management, with “many providers preferring to focus on their traditional encounter-based approach as opposed to population management.” Thirty-eight percent of the plans said coordination with providers was the most important factor in making chronic care management plans work.

NEXT: Strengthening patient/provider engagement

The provider preference for encounter-based care is more a function of “tradition and habits” than of reimbursement levels, says Soeren Mattke, MD, the study’s lead author and a senior scientist with the RAND Corporation, the sponsor of the study. “Some of these management-based care models actually pay a lot more than encounter-based care, because the price per visit is actually quite low for some of these payers.”

The 2015 Medicare Physician Fee Schedule includes, for the first time, a billing code to pay for staff time spent developing and implementing a care plan for patients with multiple chronic conditions.

The study finds that health plans are using a variety of strategies to strengthen patient and provider engagement and improve the effectiveness of their chronic care management plans. Among these are:

Collaborating more closely with providers by, for example, placing health plan staff members in practices that care for a large number of patients covered by the plan,

Helping practices redesign payment and delivery systems so that they better serve the needs of chronically ill patients,

Greater use of patient support technology, such as telemedicine, remote monitoring, and social media applications, and

Focused interventions, such as the use of predictive modeling to identify patients for disease or case management, or algorithms for predicting high-cost events such as exacerbations and hospital interventions.

The authors note that no clear scientific evidence exists as to what combinations of interventions, and their relative intensities, will lead to improved outcomes for patients with chronic diseases.

Physicians are used to the encounter-based payment model out of habit and so are unwilling to give it up. Essentially the older ones are saying, ‘why would we want to experiment with a whole new way of doing business, I’m too close to retirement, I went through the whole HMO thing and got badly burned so I’m not interested.’

Doctors wouldn’t necessarily get paid more for encounter-based care. Some of these management-based care models pay a lot more than encounter-based care, because the price per visit is actually quite low from these payers.

So you don’t think the economic aspect plays into this? – No. It’s really more tradition and habits than being able to make more less money.

Second question had to do with difference in responses as to importance of provider coordination. Why think it might be? – I think these small plans typically are regional plans, asnd they tend to be more a part of the community. They’re often even run by the physicians. One that they have as one of the case studies was originated bhy the local proviers because thye felt medical care int heir community was becoming unsustainabnle. So they said well we as docs will get together to organize health plan, we work together to maintain access. And of course those kinds of arrangements make it much more likely that you also cooperate. It’s much harder if you do that, say, from a corporate office in Chicago for all the midwest.

Going back to the reimbursement question, do you think the new CCM codes will have an impact? – It’s not that physicians don’t want to provide chronic care management, it’s just that prior to these reimbursement codes there wasn’t really a way to get paid for it. So yes, the reimbursement codes make it possible under the traditional FFS system to get paid for some ongoing care management, but at the same time if you have a non-FFS payment system you could just say