The need for better management of chronic conditions is urgent. About 141 million people in the United States were living with one or more chronic conditions in 2010, and this number is projected to increase to 171 million by 2030, when almost every other American will be living with one or more chronic conditions (Robert Wood Johnson Foundation, 2004). Unless these chronic conditions are managed effectively and efficiently, the implications of these numbers for morbidity and mortality, workplace productivity, and health care costs in the coming decades will be staggering. For example, one estimate projects that by 2034, the number of people with diabetes will double to 42 million and...

The need for better management of chronic conditions in the United States is urgent. According to estimates, about 141 million people in the United States had one or more chronic conditions in 2010. That number is projected to increase to 171 million by 2030, meaning that almost every other American will live with one or more chronic conditions (Robert Wood Johnson Foundation, 2004). Although the prevalence of many chronic conditions increases with age, a large number of the chronically ill are under 65 years of age and are covered through private health insurance. In 2009, this subset accounted for about...

This section describes which programs health plans offer to improve chronic care management, what the range of services under those programs is, which types of patients and conditions they target, and what the reasons for their adoption were. We find that the availability of chronic care management programs has become the industry standard for health plans. Their adoption is driven by the need to reduce costs and purchaser demands, as well as the desire to improve members’ heath and clinical care. A broad range of services is offered in chronic care management programs. Plans concentrate their efforts on the most...

This section depicts the approaches that plans are taking when designing chronic care management programs. We find that a set of common principles guides program development and maintenance, and we observe similar use of patient stratification and trends in program operation. In general, there is a sense among health plans that they have to be flexible in their program design and that they have to continue to evolve: As one survey respondent put it, “We know we need to continually refine pieces of chronic care management to work better; drop pieces that don’t work and add new pieces; [we] have...

This section summarizes the range of tools and modalities that plans use to reach out to their members, recruit them for program participation, and deliver services. About half of the surveyed plans use member incentives (e.g., gift cards, lower premiums) to improve patient engagement in their chronic care management programs. In all cases, plans are attempting to personalize their interactions and interventions by tailoring program delivery based on patient characteristics and readiness to change. By the same token, the use of such technologies as remote monitoring and tele-visits is expanding. As expressed by one respondent, plans feel that they need...

This section portrays how health plans are attempting to coordinate their chronic care management programs with providers. We find that health plans are aware that their programs for managing patients with complex chronic conditions can only succeed when they are coordinated closely with providers, and we observe fundamental changes in how plans attempt to coordinate care. Historically, plans interacted directly with members through telephonic and sometimes in-person communication and kept providers informed about their activities. While this model remains common, it is gradually being replaced by closer integration of provider and plan activities, either through embedding plan staff and tools...

We learned that plans conduct regular evaluations of their chronic care management programs. The primary objectives are to determine whether programs meet their goals and targets, and to improve operations. Findings are mainly used to inform business decisions and to report back to employer-purchasers; they are rarely reported to external audiences through, for example, peer-reviewed or trade publications. Plans report largely positive results in terms of cost savings, clinical improvement, and patient satisfaction.²

All surveyed plans have developed the capability to conduct regular evaluations of their chronic care management programs. Evaluation is usually divided into internal business intelligence to improve...

Plans report multiple obstacles to getting the most out of their chronic care management programs. Patient factors are perceived to be the most challenging, followed by provider factors (Figure 7.1). Other barriers include the complexities of programs stemming from need for coordination with multiple relevant stakeholders, and program costs. The impact of regulations varies; while antitrust regulation is at the bottom of plans’ concerns, state and federal privacy rules are considered to be an important obstacle. Plans report that they face challenges to engage members in their chronic care management programs on several levels. As stated earlier, contacting members identified...

Chronic care management has become a standard component of health coverage, as health plans regardless of size, location, and ownership status are including it in their products. Plans usually combine disease management for patients with common chronic conditions with case management for high-risk members, regardless of the underlying condition. The main driver for the strong uptake of chronic care management is that plans see a win-win situation, because they believe that it allows them to both improve care for their most vulnerable members and reduce the cost of coverage. The clearest evidence for plans’ trust in chronic care management is...