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The Challenge of Managing Multiple Chronic Conditions: Opportunities to Improve Quality Scores

Friday, July 13, 2018   (0 Comments)
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As community health centers likely know all too well, three in four Americans over the age of 65 have two or more chronic health conditions, such as diabetes, hypertension, arthritis, or cancer. These individuals may struggle to manage their health in a way that allows them to maintain their wellness and independence.


Due to the complexity of multiple chronic conditions, providers may also be challenged to provide adequate care for these individuals, given that Medicare covers only one Annual Wellness Visit per year. During the face-to-face time in these interactions, patients may feel too time pressed to share, or understand the necessity of sharing, all of the information pertinent to their overall health. Providers may not have time to probe on potential health challenges or socio-behavioral issues that can influence outcomes.

In order to better understand whether these limitations create gaps in care - and what those gaps mean to patient health - Quest Diagnostics commissioned independent research with primary care providers (PCPs) and Medicare patients with multiple chronic conditions.

The findings, presented in the report, "Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions," show that providers feel unable to address patients' comprehensive needs. Providers cite time limitations, while patients' professed satisfaction with their care may mask social and behavioral risks and needs. These findings suggest that the traditional medical care model of an annual provider visit may be insufficient for Medicare patients with multiple chronic conditions.

  • Nearly all providers (95%) said they entered primary care to care for the "whole patient"
  • Yet, 85 percent say they are too pressed for time to address complex clinical issues
  • 66 percent say they don't have time to address social and behavioral issues, such as loneliness or financial concerns that could affect their patients' health
  • More than four in ten patients (42%) believe that seeing their physician only 1-2 times a year to manage their multiple conditions "is just not enough"


At the same time, the recent changes in quality metrics reporting under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Merit-based Incentive Program (MIPS) make it even more important to meet the quality outcome goals for these and other patients.

To meet the needs of these patients and to help improve quality metrics, a long standing shift to move beyond health center walls is accelerating - helping to aid providers in assessing individuals and populations and closing gaps in care.  Some of these initiatives have focused on Chronic Care Management (CCM). These services often involve non face-to-face interaction (such as by phone) between a nurse and a qualified patient. CCM services can supplement the care PCP provide to patients on Medicare with multiple chronic conditions. Typical areas of focus include medication management, coordinating visits with hospitals and other providers, personalized guidance on setting health goals.

CCM services are reimbursed by the Centers for Medicare & Medicaid Services (CMS) for Medicare beneficiaries with two or more chronic conditions. CMS estimates 70 percent of Medicare beneficiaries-roughly 35 million people-are eligible for CCM services.


To learn more and explore these topics, join a webinar on August 22 from 12:00-1:00 PM Pacific. Register here for this free webinar presented in partnership with Quest Diagnostics. 





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