Helping People Live Well with Chronic Diseases

Coordinated health care for all Americans is incredibly important. But it is especially critical for people with multiple chronic conditions.

One in four Americans has more than one chronic condition such as heart disease, cancer or diabetes. And a person with multiple chronic conditions may have not just a primary care doctor, but a cardiologist, a kidney specialist, and a mental health counselor, for example, all of whom provide care. Ensuring that care is coordinated—making sure each provider knows what tests that person has taken, what medications she is on, and what her medical history is– is not always an easy thing to do.

In fact, people who are dealing with several illnesses together are at greater risk of disability, hospitalizations, readmissions, adverse drug events, and even death than those who are not.  Caring for people with multiple conditions is also costly.  In fact, two-thirds of health dollars in the U.S. are for patients with two or more chronic conditions, and 93 percent of Medicare spending goes to care for this population.

But thanks to the Affordable Care Act, we are beginning to see more coordinated care by encouraging providers to work together.  In the last few weeks, the Department of Health and Human Services (HHS) has launched a number of initiatives to achieve coordinated care for beneficiaries with Medicare. 

The release of final regulations governing Accountable Care Organizations (ACOs) which facilitate coordination among  your many providers along with another project to help community health clinics become “medical homes” for those with Medicare demonstrate this commitment.

We have also compiled a Strategic Framework on Multiple Chronic Conditions, which identified 111 programs, activities and initiatives across the HHS that focus on improving the quality of life and health status of people with multiple chronic conditions. 

Many of the programs include efforts to prevent chronic diseases, develop comprehensive health homes (a single provider or practice to coordinate care), and integrate primary care and behavioral health for people with multiple chronic conditions.   Other initiatives support the use of self-care through expansion of the Chronic Disease Self-Management Program.   Others fund comparative effectiveness research to optimize prevention and care for those with multiple chronic conditions.

Implementing strategies of the framework – whether developing new care models, empowering individuals, equipping providers with tools, or enhancing research – should result in better care, better health and lower costs.

Ultimately, we need to help people take preventive measures and we need to ensure our health care system is prepared to meet the needs of those who must deal with multiple chronic conditions. Using the tools we have, including those provided by the Affordable Care Act, we can improve the health of those who live with multiple chronic conditions and lives of Americans.