Why chronic care management isn’t gaining traction

February 5, 2020
Drew Kearney, JD
Volume 97, Issue 3

The top three barriers identified.

Managing patients with multiple chronic conditions-who, according to the RAND Corp., account for about a quarter of the U.S. population but more than two-thirds of healthcare costs-is critical to success in value-based models.

The only problem? The health system was purpose-built for episodic care rather than the ongoing, community-based care this population typically needs.

To learn more about the challenges of managing chronic care, Sage Growth Partners conducted a survey of over 100 healthcare leaders in early 2019. Respondents were roughly equally divided between health system executives and leaders of physician practices.

What we found is a large gap between need and ability. While virtually all (98 percent) respondents believe chronic care management is very important, only about half (53 percent) say they’re doing it very well.

Top three barriers 

What’s getting in the way? Respondents say their main barrier is insufficient human resources (61 percent), followed by inadequate reimbursement (52 percent), and capital constraints (35 percent).

It’s not surprising that managing the care of those with chronic conditions is difficult. Nor is it surprising that-despite the emergence of thousands of new technology solutions-respondents think people are essential to managing care:

  • 71 percent of respondents say that an even mix of people and technology is needed to drive care management success, while 19 percent think staffing is more important than technology.

  • Over two-thirds (69 percent) of respondents believe a trusted relationship with a nurse or other clinicians is central to managing chronic conditions, and 76 percent say these relationships are extremely likely to improve patient loyalty.

Overall, the industry is sober about its ability to manage chronic care and readmissions, and hospital executives are less sanguine about their abilities than are leaders of physician practices:

  • Only 4 percent of hospital leaders say they manage care “extremely well,” compared with 29 percent of physician leaders.

  • Only 24 percent of hospital leaders rate their effectiveness at preventing readmissions as very/extremely good, compared with over half (56 percent) of physician group leaders.


Why is there such a big gap? The survey findings reveal that only 20% of hospital executives believe office-based care is most important, compared with 75 percent of those running physician practices. That indicates that physician leaders view office-based care as key to managing chronic conditions, while hospital executives appear to place a greater value on home-based care. Or, perhaps, physicians feel more in control of care delivered outside the hospital than do hospital leaders.

Where both groups agree: telephonic nurse outreach is the second most important type of care.

Making CCM work

The CMS Chronic Care Management (CCM) program has been available since 2015, when CMS established new reimbursement codes to cover the cost of managing chronic care remotely. While this was a step in the right direction, it appears that only a small percentage of Medicare patients are actually receiving care under these codes.

The survey findings indicate that CCM reimbursement isn’t sufficient to cover the costs of delivering care in this program. Many providers struggle to enroll enough patients in this program to cover their staffing and technology time and costs. And even a number of chronic care management companies have folded because they couldn’t make the model work.

Creating a pool of experienced nurses that can work closely with physicians’ staff to give the higher acuity patients the extra support they need-to catch problems early so they don’t become crises-is key. It’s also important to have technology that can readily integrate with the EHR so that physicians don’t waste precious time getting the program up and running.

When programs are implemented effectively, health systems with 1,000 enrolled Medicare patients can generate an additional $500,000 in annual revenues, without spending a dime up front.

The challenges of delivering chronic care are multiple and significant. But for those who can operationalize this care model with the right combo of people and technology to make a program work, the rewards can be great.

Drew Kearney is co-founder and CEO of Signallamp Health, Inc.

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