The growing burden of managing chronic illness has long been a critical issue for policy makers and clinicians seeking to improve the quality, cost and efficiency of healthcare systems in the United States. According to the Institute of Medicine, the costs of treating and managing the segment of the population living with chronic illnesses currently represents nearly $1.5 trillion of the over $2 trillion in annual healthcare spending in the U.S. Over 90% of Medicare costs are allocated to beneficiaries living with two or more chronic conditions, with close to 50% of spending on individuals living with 6 or more chronic conditions (approximately 14% of beneficiaries). The immense share of healthcare spending attributable to chronic illness is expected to climb as the population ages.
Earlier this month, a bipartisan bill entitled the Better Care, Lower Cost Act was introduced in Congress which aims to address the complex issues involved in chronic care management. The legislation outlines three key innovations toward this end.
First, the bill seeks to incentivize a more accountable and integrated approach to managing chronically ill Medicare patients through the establishment of Better Care Programs (BCPs). Unlike accountable care organizations (ACOs), BCPs represent a fundamental departure from the traditional fee-for-service model of care; instead, BCPs would receive risk-adjusted “monthly payments of a capitation amount for each BCP eligible individual enrolled,” and would be eligible for shared-savings and quality bonuses for meeting specified criteria. BCPs would also jettison traditional attribution rules and in so doing would encourage the formation of multidisciplinary teams of healthcare professionals who could focus specifically on caring for patients in need of coordinated chronic care management.
Second, the bill envisions the creation of Chronic Care Innovation Centers (CCICs). CCICs would be charged with the mission of researching, designing and implementing comprehensive strategies to improve the quality of chronic care management across a variety of governmental and private sector programs, and would develop best practices for caring for the chronically ill.
A third component of the proposed legislation encourages reforms in medical education. The bill calls for medical schools and residency training programs “to routinely develop new, forward thinking, and evidence-based curricula that addresses the tremendous need for team-based care and chronic care management. Such curricula shall include palliative medicine, chronic care management, leadership and team-based skills and planning… leveraging technology as a care tool.. and shall include appropriate focus on care practices required for rural and underserved areas.” To incentivize these progressive innovations in medical education, the legislation recommends linking direct and indirect graduate medical education (GME) payments to fulfillment of specific curricula requirements.
The reforms envisioned by the proposed legislation represent novel ways forward for chronic care management in the United States. Among the most striking features of the bill is its focus on medical education and graduate training, a dimension of our healthcare infrastructure that is often overlooked in public and political discourse. While the future of the legislation is uncertain, the issues it seeks to address are bound to become increasingly prominent as the prevalence and burden of chronic illness continues to escalate.