The Emergency of Chronic Disease Management

How many families have stories of an aging, frail parent who is discharged into the care of only a marginally healthier spouse? My family does. Perhaps yours does, too.

It's often only a matter of weeks until the realization that the burden of medication adherence, nutrition, mobility, hygiene, and continuous care is beyond an elderly spouse or intermittent caregiver. The deterioration of the patient's condition is almost a certainty.

No one is surprised when an ambulance arrives to re-admit them to the hospital – often in worse condition than on discharge. Many are pre-septic or septic or suffering from acute pulmonary distress and advanced heart failure.

Why is this such a familiar story? Can we do better as a health system? Do we have enough inpatient beds? Do we have adequate covered services within long-term care and step-down facilities? Are there enough covered outpatient services for Medicare Part A-only patients?

Importantly - Do our nation’s stressed primary care providers have the capacity to monitor a patient’s health status as often as needed – in alignment with their proposed care plan – after a discharge event or diagnosis that requires frequent oversight?

Of course not.

To address the issue, CMS has expanded the billable codes to provide appropriate services to post-discharge patients and other patients with multiple co-morbidities, who are at higher risk without proper outpatient care and surveillance.

High-risk patients without proper remote care, including telehealth, home care, and chronic disease management programs, contribute to expensive hospital readmissions, emergency room visits, and long-term complications. These events contribute heavily to rising healthcare costs.

The estimated annual cost burden on the federal healthcare budget for patients who do not receive appropriate transitional care management (TCM) or proper post-discharge care is significant.

Medicare Costs - Hospital Readmissions

The Medicare Payment Advisory Commission has reported that preventable hospital readmissions cost Medicare an estimated $26 billion annually, with $17 billion attributed to avoidable readmissions.

Preventing Deterioration and Readmission

The Center for Medicare and Medicaid Services has provisioned reimbursable billing codes for remote patient monitoring, transitional care, and chronic disease management. These services can be provided without additional burden to the physician’s practice. Third-party solutions with clinically certified staff can perform the required assessment, engagement, enrollment, monitoring and documentation, and data integration with the Practice EHR.

Effective use of TCM (CPT 99495, 99496) and remote patient monitoring (RPM, CPT 99453, 99454) can help prevent unnecessary readmissions by ensuring patients receive proper follow-up care, medication management, and monitoring after discharge.

Emergency Room Visits

Avoidable emergency room visits are another primary driver of healthcare costs. Each visit costs an average of $1,389. It is estimated that preventable emergency department visits contribute to $8.3 billion annually in excess healthcare spending, much of which can be mitigated through remote monitoring and early intervention for chronic conditions.

Remote Patient Monitoring for patients with chronic diseases, if adequately implemented post-discharge, can identify early signs of deterioration, preventing the need for emergency room visits. This is particularly true for conditions like heart failure, diabetes, and COPD.

Long-Term Care and Complications

Failure to manage chronic conditions after discharge often increases the likelihood of patients entering long-term care or skilled nursing facilities (SNFs). The average annual cost of a stay in a nursing home is $82,000, and Medicare and Medicaid together bear a significant portion of these costs.

Again, properly using chronic care management (CCM) codes (CPT 99490, 99439) and RPM codes can help patients manage conditions like diabetes, hypertension, and congestive heart failure at home, delaying or preventing the need for long-term institutional care.

25% of all Medicare patients discharged from a hospital are readmitted within 30 days

This is due primarily to a lack of follow-up care, inadequate transitional care management, and poor chronic disease management post-discharge. The cost to the Center for Medicare and Medicaid Services for hospital readmissions is estimated to be between $41 and $54 billion annually, much of which is avoidable with better post-discharge care.

We can do better.

Understanding how to implement successful Remote Patient Monitoring and Chronic Disease Management programs without burdening clinical staff is important. This model has been proven successful in large US health systems, rural health systems, FQHCs, and private specialty practices.

It should be considered a best practice.

For more information on which health systems have successfully achieved better outcomes, improved patient satisfaction, and measured success, you can DM me or reply.