Chronic diseases and conditions such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis are among the most common, costly, and preventable of all health problems, according to the CDC. In fact, about half of all adults in the US—117 million people—had one or more chronic health conditions, while one in four adults had two or more such conditions. Further, the CDC notes, seven of the top 10 causes of death in 2014 were related to chronic disease. Two of these—heart disease and cancer—together accounted for nearly 46 percent of all US deaths that year.
Health plans, perhaps more than any other stakeholders in the US healthcare system, are acutely aware of the financial burden of chronic disease. The CDC reports that 86 percent of the nation’s $2.7 trillion annual healthcare expenditures are attributed to people with chronic and mental health conditions. According to a report from the Partnership for Solutions, a national program whose goal is to improve care and quality of life for Americans with chronic health conditions, “People with chronic conditions, particularly those with multiple chronic conditions, are the heaviest users of healthcare services. Higher utilization appears in all major service categories: hospitalizations, office visits, home healthcare, and prescription drugs. For example, individuals with multiple chronic conditions account for two-thirds of all prescriptions filled, and those with five or more chronic conditions have an average of almost 15 physician visits and fill over 50 prescriptions in a year.”
In addition to the rising incidence of chronic disease, the number of health plan members over the age of 65 is growing, statistically placing them at a higher risk for chronic illness. As it is often these aging populations who develop chronic diseases or require more frequent care, this only adds to the financial burden that health plans are shouldering. It is therefore more important than ever for health plans to develop a strategy for maintaining the health of their members, improving patient outcomes while reducing costs.
Managing Member Health
Traditionally, payers have focused on a few key efforts to maintain member health including Utilization management, Wellness and care management, and Complex case management.
The challenge inherent in these methods of care management is not that they are ineffective, but that they are not personalized to address the complex clinical needs unique to the individual patient. On one end of the spectrum, such care management initiatives focus on population health, emphasizing efforts that are good for an entire population in general, such as the previously mentioned annual eye exams for members with diabetes. These population health efforts are of course necessary and prudent, but they’re not personal.