Investing in the Future of Chronic Care Management

A chronic condition is a physical or mental health condition that lasts more than one year and causes functional restrictions or requires ongoing monitoring or treatment.

Chronic diseases are among the most prevalent and costly health conditions in the United States.  According to the CDC, 6 in 10 adults in the U.S. have a chronic disease and 4 in 10 adults have two or more. The main chronic diseases for gastroenterology include IBD, Cirrhosis, IBS, NAFLD/NASH, obesity, GERD, and other chronic liver diseases such as HBV and HCV.

Recognizing that many of its patients have some sort of chronic condition, Allied Digestive Health’s physicians are coordinating care across multiple health teams, with the goal of reducing complications, lowering the cost of care and increasing the level of patient satisfaction. To stay on top of patients’ wellness and treat and monitor symptoms, Allied Digestive Health has developed chronic care management services for patients with two or more chronic diseases. The process includes formulating a comprehensive care plan, communication, medication management, and coordination of care.

Chronic care management has many benefits for patients. One major benefit is the communication between providers to fully understand key information such as new medications and the impact they have on a chronic health condition. This helps ensure that providers have a comprehensive picture of a patient’s overall health. Additionally, coordination of care is a major focus for chronic care management including improving the process for monitoring, asking questions, and reporting any changes in symptoms. Chronic care management can also help reduce overall healthcare costs through continuous monitoring and improving the likelihood of treating conditions early on or preventing them altogether.  Allied has successfully worked with the payor community to demonstrate that the number of hospitalizations and overall cost of care has been reduced.

As we bring light to the importance of chronic care management in gastroenterology, we took the time to speak with Allied Digestive Health’s Chief Medical Officer, Nadeem Baig, MD on his insight regarding the benefits and future of chronic care management.

What does chronic care management mean for patients?

“Patients get more frequent, direct, and personal attention and care from nurses and other clinical personnel to actively monitor their chronic illnesses. Nurses and other staff can take as much time as needed to educate and counsel patients on their medications, diet, and behaviors to increase their level of wellness. Further, care plans are tied to providing more holistic care that is centered around the patients’ needs and goals. All such care is delivered under the direction of patients’ supervising physicians. The patient care can be done over the phone or in the physician’s office,” Nadeem Baig, MD.

How receptive have the payors been in regard to chronic care claims? Does this fall under value-based care?

“Some payors are covering either all or some variation of chronic care services, such as remote patient monitoring.  The desire is to increase overall wellness in a patient population that previously was not receiving holistic care.  The goal of value-based care is to provide higher quality care that is more cost effective to a defined population of patients, thus meeting the “Triple Aim” in healthcare. Chronic care management has been proven to meet the goals of value-based care. The Center for Medicare and Medicaid Innovation (CMMI) reported that CCM reduced Medicare beneficiary costs by $74/month over an 18-month period in large part by reducing hospitalizations, ER visits, and nursing home costs,” Nadeem Baig, MD.

Where do you think chronic care management is headed in the future?

“Chronic disease is the one of the primary drivers of increasing healthcare costs in the U.S. Further, chronic diseases are often complex and inter-connected, such that affecting one condition positively or negatively will impact others. Yet, current care between the patients, their primary care physicians, and specialists are fragmented and isolated from each other. Chronic care management, as outlined and supported by CMS, seeks to bridge the divide by investing in a “team-based” approach toward navigating and coordinating care with nurses, health coaches, dieticians, therapists, and other clinical staff. They will be led and guided by the patients’ treating physicians, who will be armed with abundant healthcare data to help grade and predict patients’ course in efforts to keep their diseases from deteriorating. This will be the standard way of managing patients with multiple chronic diseases in the years and decades to come,” Nadeem Baig, MD.

Allied Digestive Health’s investment in chronic care management will help transform patient care for its patient population while significantly improving the overall quality of life for its patients while simultaneously reducing hospital/emergency room visits.

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