Nearly 60 million Americans are covered by Medicare and about 10,000 become eligible for Medicare every day. High-risk beneficiaries and those dealing with multiple and complex chronic diseases are driving cost and quality of care concerns.
Medicare primarily functioned as a fee-for-service (FFS) system where the volume of services delivered, not value, drove payment. This contributed to increased costs with a minimal focus on improving the quality of care. Consequently, the Centers for Medicare & Medicaid Services (CMS) began to look for a different payment system that encouraged incentives for value delivered and that recognized quality of care. The change from fee-for-service to value-based care had already begun in the commercial insurance sector as the large health plans looked to lower costs, spread risk and address quality of care issues.
As the prevalence and associated costs of chronic diseases continue to grow, healthcare stakeholders, including payers, are focusing on performance and population health program (PHM) measures of chronic conditions for reimbursements and value-based incentives.
Provider groups taking on risk have initiated disease management (DM) programs for patients with common chronic diseases, and complex case management (CCM) programs for patients who experience critical or traumatic health events, or who have highly complex and high-acuity diagnoses. Core to both DM and CCM programs are requirements for care managers to address behavioral health problems or socioeconomic challenges. Effective care coordination programs have the capability to focus on building relationships with patients and primary care providers. This can allow provider groups and payers the ability to demonstrate improvement in preventive care and quality measures.