When I began training for Ironman competitions, it immediately became obvious that if one part of my regimen was off, everything else suffered with it. Preparing for a grueling race that involves swimming over a mile, biking for 56, and running a half marathon, all back-to-back, meant that everything I did had to support my goal. This meant it had to extend beyond training and technique to hydration, nutrition, and sleep. I knew that any injury or deficiency could lead to others. Even poor sleep could trigger negative diet changes, creating a downward spiral that could impede my performance.
Treating patients with comorbid chronic conditions (multiple chronic conditions that occur in a patient at the same time) requires a similar approach. This is because one chronic condition, or even its treatment, can exponentially exacerbate other co-existing conditions. For example, heart medication can affect the kidneys, which can be a major issue when a patient experiencing heart failure also has kidney disease. Those with diabetes experience hardening of the arteries, and when that patient also has high blood pressure, those brittle arteries make these patients more vulnerable to a stroke. With comorbid conditions, it's easy to see that nothing in the body happens in isolation.
If not managed properly, comorbidities come with significant costs for the patient and employer, including reduced quality of life for the patient, hindered employee productivity in the workplace, and greater medical expenses. In fact, though 26% of patients have comorbidities, they account for 50% of total medical cost1. But treating patients with comorbidities – and saving on the associated costs – is possible with active management of all aspects of the patient's health. Here at Kelsey-Seybold, primary care physicians work hand in hand with specialists and our Disease Management and Population Health Programs to care for high-risk patients, including those with comorbidities.
Running with Disease Management
Accountable Care Organizations like Kelsey-Seybold Clinic are specifically resourced to manage comorbidities. An ACO-based and physician-led disease management program, powered by clinical data within a robust electronic medical record, is designed to regularly engage patients with certain chronic conditions, especially those with more than one chronic condition, to help with ongoing proactive management. In this type of program, patients are more likely to visit their primary care physician, receive routine screenings, and have better control of chronic conditions, helping them to save more than $1,200 per year, according to the Health Policy Institute2.
But what about different types of disease management programs? Some insurance plans run their own programs, looking at claims data to identify patients with comorbidities. However, the National Institutes of Health reports that disease management programs that operate at the physician practice level engage more than three times as many patients, thanks to the benefit of physician relationships, clinical knowledge, and availability of treatment programs3. And Kelsey-Seybold's engagement rate is even dramatically higher than other physician-led programs:
|
Disease Management Program |
Engagement Rate |
 Asthma/COPD |
99% |
 Chronic Kidney Disease |
99%
|
 Congestive Heart Failure (CHF) |
97%
|
 Diabetes Management |
79% |
 Hyperlipidemia |
97%
|
 Hypertension |
99%
|
With higher patient engagement, when patients actively participate in their care, comes greater management of comorbid chronic conditions – and lower total medical cost.
In Stride with Population Health
Another approach for treating patients with comorbidities is to provide even more high-touch care through a population health program. At Kelsey-Seybold, Population Health uses clinical data to take a proactive role in identifying patients who haven't been getting the care they need and then engages with patients in their own homes to identify barriers to care – such as lack of transportation, the expense of treatment, mental health issues, and beyond. Our Population Health team then works directly with patients, bringing care
to them. For patients with comorbidities, this type of hands-on approach may be the difference between life and death.
Winning with Coordinated Care
Proactive Disease Management and Population Health programs are a component of a true patient-centered "medical home" model that encourages partnerships between patients and providers. Through these partnerships and coordinated care, physicians can actively manage chronic conditions to help improve care quality and efficiency. It's a winning strategy that may help keep patients with comorbidities healthier and more productive while lowering medical cost for employees and employers.
1 Charlson M, Charlson RE, Briggs W, Hollenberg J. Can disease management target patients most likely to generate high costs? The impact of comorbidity. J Gen Intern Med. 2007 Apr;22(4):464-9. doi: 10.1007/s11606-007-0130-7. PMID: 17372794; PMCID: PMC1829434.
2 "Disease Management Programs: Improving Health While Reducing Costs?"
Health Policy Institute, Georgetown University, 13 Feb. 2019, hpi.georgetown.edu/management/.
3 Annis AM, Holtrop JS, Tao M, Chang HC, Luo Z. Comparison of provider and plan-based targeting strategies for disease management. Am J Manag Care. 2015 May;21(5):344-51. PMID: 26167701.
Author
Steffanie Campbell, MD, FACP
Department of Internal Medicine at Pearland Clinic
Learn More
