The Big Five: Chronic Care Management


Chronic diseases are a national epidemic. According to the Centers for Disease Control and Prevention (CDC), chronic diseases and conditions- such as heart disease, stroke, cancer, type 2 diabetes, obesity and arthritis- are the leading causes of death and disability in the United States, and yet that are among the most common, costly and preventable of all health problems. In fact, as of 2012 half of all adults (117 million people) have one or more chronic health conditions, and 1 in 4 adults have 2 or more chronic health conditions, as do 1 in 15 children. As a healthcare provider, chronic conditions play a massive role in your organization’s daily patient care and yet it has quickly become the most expensive sector in the industry, accounting for approximately 86% of total healthcare spending.

Managing chronic conditions can be expensive, but the cost of readmissions can be devastating for the financial health of healthcare organizations, specifically hospitals, as chronic illnesses are felt more strongly in minority and low-income populations who have a greater chance of being uninsured or under-insured. In 2014, the estimated total annual costs of readmissions for Medicare was $26 billion, with $17 billion of that considered avoidable costs. Readmission penalties are affecting every state across the U.S. In fact, this Kaiser Health Foundation article examined the readmission rates from all fifty states showing states where a majority of hospitals are facing penalties such as New Jersey (98 percent), Connecticut (88 percent) and Delaware (86 percent).



What solutions are there? Technology and telemedicine can help to effectively treat and manage the chronic conditions of your patient population. Remote patient monitoring (RPM) technology has been proven to help manage and monitor chronic conditions, especially when utilizing telemedicine in the home. RPM uses digital technology to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to healthcare providers in a different location for assessment and recommendations. Programs can collect a wide variety of data such as vital signs, weight, blood pressure, blood sugar, oxygen levels, heart rate and electrocardiograms. Health professionals at primary care centers, hospitals, intensive care units, skilled nursing facilities and more can then view the transmitted data and act on information as part of their patient’s treatment plan. The CDC estimates that eliminating three risk factors- poor diet, inactivity and smoking- would prevent 80% of heart disease and stroke, 80% of type 2 diabetes and 40% of cancer. All these factors can be fully or partially monitored and managed through RPM telehealth technology.

But has telemedicine been proven to actually work for treating chronic care patients? A 2015 study that investigated acute care utilization outcomes during a 90-day transitional tele-monitoring program found a 50% reduction in 30-day readmission and a 13-19% decrease in 180-day readmission among patients who received the tele-monitoring intervention. Between 2003 and 2007, the Veteran’s Administration (VA) introduced a national home telehealth program known as Care Coordination/Home Telehealth (CCHT). Among the 445 veterans with type 2 diabetes enrolled, 50% saw a decrease in number of hospitalizations and an 11% decrease in emergency room visits.

So, why hasn’t everyone jumped on the RPM bandwagon? The answer lies in CMS’ slow response to providing reimbursement for such services. As all healthcare providers know, reimbursement for services is the cornerstone to a successful and healthy revenue mix and cycle. Healthcare providers of all shapes and sizes simply cannot afford to provide services that are not reimbursed by CMS. Currently, Medicare only reimburses for specific telehealth services when they are delivered via live video (traditional telehealth) with limitations based on provider type, facility type and geographic location. Store-and-forward delivered services are prohibited (except for CMS demonstration programs in Alaska and Hawaii) and remote patient monitoring is not reimbursed at all.

Several state and national associations such as the American Telemedicine Association and others are actively working on pushing CMS to start reimbursing for more 21st century healthcare technology services including all types of telehealth and telemedicine.

What has CMS done to help encourage proactive, preventative management of chronic conditions? Proactively managing those patients and their chronic conditions has been shown to lower the overall cost of providing care and as of 2016, there is a way for rural health clinics (RHCs) and federally qualified health centers (FQHCs) to be paid for it.

On January 1, 2015, CMS introduced the Medicare Chronic Care Management Program, a telehealth-enabled initiative aimed at helping healthcare providers better treat patients with multiple chronic conditions. The program includes RHCs and FQHCs, and the idea is to use monthly 20-minute care coordination sessions with patients with 2 or more chronic conditions, in an effort to reduce preventable readmissions, emergency room visits, nursing home intakes and other utilization costs that many times do not positively affect a patient’s long-term health. While reimbursement prices vary according to Physician Fee Schedule, the average monthly reimbursement is $42 per month per beneficiary. While many doctors have cited increased documentation time and staff needed as negatives for the small reimbursement amounts in this program, we must continue to push CMS to catch up with the amazing healthcare technologies already at work.

Has your organization used technology or telehealth to manage chronic conditions? We would love to hear from you! Email us at!