Unveiling The Impacts of Chronic Diseases
According to the Centers for Disease Control and Prevention (CDC), chronic diseases are responsible for 70% of deaths in the United States, becoming the leading cause of disability and death. Chronic disease is an on-going global health challenge that significantly compromises the individuals’ quality of life and disproportionately burdens vulnerable communities. Due to lack of information sharing and access to care, individuals were often left dissatisfied with their experience in healthcare and had a greater risk for negative health outcomes. Value-based care (VBC) can bridge the growing gaps in care by utilizing tools such as Remote Patient Monitoring (RPM) and Chronic Care Management (CCM).
What is VBC?
VBC focuses on the quality of care provided by the physicians and utilizes collaborative efforts from different healthcare professionals. It prioritizes patient satisfaction, provider effectiveness, and increases the value of healthcare by considering each patient’s unique health objectives. With the healthcare industry transitioning from a fee-for-service (FFS) model to VBC, it focuses more on increasing healthcare value through cost-effective approaches. This shift is a result of concerns expressed by healthcare professionals regarding the health system’s rise in costs and decline in performance. VBC was introduced to help encourage physicians to place a greater emphasis on the patient’s well-being by incentivizing their care. Supporting VBC through value-based payments (VBP) can increase reimbursements and maximize a clinic’s revenue, while achieving better health outcomes for patients. Providers can recognize the importance of VBC as it reduces the healthcare burden, improves patient outcomes, and provides higher quality care.
What is RPM and Why Does it Matter?
RPM is a healthcare solution that focuses on delivering preventative care. With the use of RPM, physicians can quickly detect abnormalities in their patients’ health and prevent any emergencies from occurring. RPM devices record patients’ vitals and report it back to their system where physicians can observe their condition. Based on the data collected, they can alter their treatment plans depending on the patient’s needs and provide them with care without needing to be present in person.
According to the Department of Health and Human Services (HHS), some of the chronic conditions that can be tracked by RPM include:
- Diabetes
- Hypertension
- Cardiovascular Disease (CVD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Asthma
- More
The digital health approach increases work efficiency by allowing physicians to simultaneously monitor multiple patients, since the devices used by patients can provide their data from outside of a traditional healthcare setting. This is useful for chronic disease management as it lowers the patient’s risk of adverse outcomes and better prepares physicians to treat their health complications. In addition, physicians can still provide care to patients who may not be able to attend in-person appointments due to their health conditions. Prioritizing early interventions and managing the patients’ health rather than treating illnesses that have significantly progressed would enhance their long-term health, reducing, if not eliminating, possibilities for future complications. RPM encourages patients to be active with their treatments, which increases their satisfaction as it allows them to feel a sense of achievement when completing their daily tasks and enjoy following their treatment plans. Furthermore, patients receiving care from the comfort of their home allows them to feel safe, relaxed, and open to their physician’s treatment procedures, becoming cooperative overtime. Ultimately, RPM plays an essential role in offering a seamless healthcare experience for patients while enabling physicians to treat them with ease.
VBC Empowering RPM’s Functionality to Prioritize Patient’s Health and Well-Being
RPM solutions can successfully deliver VBC because it enables providers to efficiently use the resources they possess and save costs. In addition, providers can easily reallocate their time to be able to attend patients that are at higher risk and treat them without compromising the care for others. By connecting to patients remotely, it allows physicians to have access to better patient reporting data, while helping patients save time and money spent on traveling. RPM tools can address social determinants of health by providing high-quality care to individuals who are at a disadvantage, due to factors such as limited access to transportation.
The benefits of RPM include:
- Cost-Effective: Allows physicians to detect issues with patient’s health and reduces healthcare costs.
- Reduces Hospitalizations: Intervenes with their treatments early to prevent unnecessary hospital visits.
- Increases Patient Compliance: Keeping patients involved throughout their healthcare journey helps improve adherence to medication and increases their satisfaction.
- Prioritizes Preventive Care: A stronger focus on being proactive with treatments and mitigating patient health risks.
- Increases Access to Care: Overcomes geographic barriers to provide care to their patients.
The Importance of CCM in Healthcare Delivery
CCM are services provided by physicians that target your health issues and aim to achieve your healthcare goals. Physicians would develop care plans tailored to the needs of individuals living with two or more chronic conditions. If patients are identified as being at risk, physicians must receive consent from them before proceeding with the care plan and be in regular contact with each other. Once an agreement is signed, patients can get the appropriate services they require and have appointments through phone or video calls for their convenience. As the prevalence of chronic conditions continues to increase, the demand for CCM services is rising. The CDC has reported that six out of ten Americans are living with at least one chronic condition. Implementing CCM programs would help address the challenges caused by chronic conditions and reduce mortality rates for avoidable diseases.
VBC Working Together with CCM to Cultivate Health Benefits
CCM equips physicians to be successful in a value-based environment by enhancing care delivery and reducing the number of unnecessary hospital visits. It enables providers to receive data insights that are required to manage their patients’ health. Avoiding excessive use of healthcare services by managing chronic diseases would help reduce avoidable mortality and disability rates. Furthermore, it addresses the concerns regarding the lack of patient compliance, as the services in CCM allow for frequent interactions between physicians and patients. Empowering patients with knowledge helps them feel in control of their health conditions and would respond positively to physician’s instructions, maintaining engagement throughout the process. As a result, it strengthens their relationship since patients become closer with their providers and are motivated to follow their care plan. By collaborating with medical professionals, it can help them adapt to lifestyle changes that foster better health outcomes and manage their overall condition.
With CCM tools, healthcare providers can:
- Reduce Patient Risk: Physicians have better control over patients’ chronic conditions and can focus on prevention.
- Increase Revenue Opportunities: Can receive higher reimbursements by incorporating CCM programs that may not have been offered by their clinic and submitting new billing claims to Medicare.
- Deliver Proactive and Coordinated Care: Working together with different healthcare professionals to identify risk factors early and help patients achieve their goals.
- Increase Clinical Efficiency: Clinics can monitor many patients and send medication reminders to ensure patients are following their care plan.
- Promote Self-management: Empowers patients to be active in their treatments and follow their care plan instructions without needing the physician’s physical presence.
How to get Started:
- Identifying Patient Eligibility: Patients with two or more chronic conditions and have been indicated to be at high risk of functional limitations, reduced quality of life, or death can be eligible for CCM. Physicians can refer to the requirements provided by CPT (such as number of medications, emergency visits, illnesses) to determine if the patient requires CCM services.
- Provide an Initiating Visit: Have an in-person meeting with the patient to establish what their health goals are and how to achieve them, as it can provide valuable insights to a physician on their needs. During this meeting, the physician must provide a detailed planning and evaluation session of the care plan with the patient.
- Receive Consent from Patient: Ensure that the patient fully understands the conditions of the treatment and sign the agreement you provided. This would allow patients to be fully aware of the costs and responsibilities they have during this process, while helping them stay engaged with their care plan.
- Develop Comprehensive Treatment Plan: The care plan provided by the attending physician should take a value-focused approach on managing the patients’ conditions and improving their quality of life. Treatments in the care plan must provide details such as a list of health issues of the patient, measurable outcomes and goals, medication management, interventions, and potential outcomes.
- Deliver Care Continuously: Provide and tailor the care plan to your patient’s needs when necessary. Making sure that patients have 24/7 access to emergency care would help avoid the use of costly healthcare services by taking proactive approaches with their treatments.
To learn more about the CCM guidelines and billing codes for additional reimbursements, refer to the Centers of Medicare & Medicaid Services (CMS) “Chronic Care Management Services” booklet here.
Conclusion:
At MDLand, we understand the importance of integrating patients into the flow of information throughout every step of their healthcare journey. Acknowledging CCM and RPM as key services to achieving VBC can help physicians recognize our modules’ capability of improving patient outcomes. MDLand’s RPM and CCM modules allow physicians to cater to the specific needs of each patient and provide insights that would help manage their patients’ conditions, achieve personalized care goals, and excel in a value-based care environment. Using our built-in patient engagement tools on iClinic®, physicians can seamlessly communicate with patients and ensure excellent healthcare experiences. Removing the obstacles affecting patients’ access to care can help reduce the disease burden of chronic conditions and forge a path towards health equity. Learn more about our CCM and RPM modules!