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Care Redesign Survey: To Improve Chronic Disease Care, Change the Payment Model
  HIV Care delivery is ineffective due to reimbursement restrictions. Jules
Insights Report • September 5, 2019
Analysis of the NEJM Catalyst Insights Council Survey on Chronic Care Models. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
Weil suggests the health care industry has to temper its need for rapid return on investment and follow the guiding principle of "doing positive things for patients, even if sometimes that positive impact may not be realized in the short term." Some diagnoses, such as depression, may or may not register improvements for years, yet "You have to be comfortable with making an upfront investment and assessing over extended periods to see improved clinical outcomes as well as improvement in total cost of care."
Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. The latest NEJM Catalyst Insights Council report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health.
"Although a very large portion of the health care spend involves managing chronic conditions, many health systems can't be more proactive because we get paid to take care of people when they are sick. We aren't paid to review populations of patients," she says, emphasizing that "the business model influences how much you can spend on proactive versus reactive care."
The top three challenges for chronic disease management, as listed by respondents, clearly demonstrate this constraint. Lack of time for clinicians to see patients with chronic conditions (selected by 44% of respondents), insufficient care coordination to ensure best outcomes (39%), and lack of patient resources for self-management (27%) are largely resolved in value-based care and capitated models, according to Compton-Phillips.
"There are many opportunities to be proactive for any illness. It could mean that every patient who's screened for diabetes and determined to have early illness receives aggressive education," Weil says. "It could mean dedicating staff to ensure that diabetes-diagnosed patients schedule and attend necessary appointments. And it could mean that patients with uncontrolled sugar receive an automatic referral to an endocrinologist."


"The vast majority of diabetics can be managed with routine chronic disease management, outreach, education, and follow-up. The rest need more, such as titrating of medications by a pharmacist, close monitoring by a nurse practitioner, or eventually referral to a diabetologist," he says. "It is important to make sure that the right level or intervention is targeted to the appropriate patient."



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