Mahatma Gandhi once said, “It is health that is real wealth and not pieces of gold or silver”. This would make United States a very poor country. Approximately one in four American lives with two or more chronic conditions. Among Americans aged 65 years and older, as many as three out of four persons have multiple chronic conditions (MCC). In addition, approximately two out of three Medicare beneficiaries have MCC. People with chronic conditions have a higher mortality and poor day to day functioning. Functional limitations often complicate access to health care, interfere with self-management, and necessitate reliance on caregivers. In addition, they incur a significantly higher healthcare cost. According to Center for Medicare & Medicaid Services (CMS), 71% of total US healthcare spending goes to treating patients with chronic conditions. Approximately 93% of CMS’ expenditure goes to treating patients with MCC. People with high health care expenses also have high out-of-pocket expenses relative to income.
American healthcare has many aspects that lead to fragmented care. Poor communication between providers, inconsistent use of Electronic Medical Records (EMR) or lack of interoperability between EMRs, and a physician payment system that does not reward efforts to co-ordinate care. Care co-ordination is important to reducing care fragmentation. McDonald et al. defined care co-ordination as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” This definition fails to recognize socioeconomic and behavioral determinants of health as a contributor to healthcare outcomes. According to the Wisconsin County Health Rankings, health is determined by a number of health factors including the quality of health care, health behaviors, socioeconomic factors and the physical environment. They have shown that clinical care contributes only 20% to health outcomes. Therefore, health behaviors, socioeconomic factors and physical environment have a much larger impact on health outcomes. The National Coalition on Care coordination defines care co-ordination as “a person-centered, assessment-based, interdisciplinary approach to integrating health care and social support services in which a care coordinator manages and monitors an individual’s needs, goals, and preferences based on a comprehensive plan.”
CMS has recognized Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. The individual requirements place emphasis on care-coordination and lay the groundwork for providers to be reimbursed for their efforts. Unfortunately, the requirements place unnecessary burden on individual and small practices. Please, visit CMS’ website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf for more information.