HISTORY

States were among the first to experiment with chronic care management due to the fact that Medicaid beneficiaries with chronic illnesses make up a huge portion of Medicaid spending.  In the late 1990s, several states began to implement programs to help control the expense of costly chronic diseases that plague the Medicaid population.

One of the earliest adopters of chronic care management was Florida. In 1997 and 1998, the Florida legislature established a care management program for Medicaid beneficiaries to address diabetes, hemophilia, asthma, HIV/AIDS, end stage renal disease, congestive heart failure, cancer, sickle cell anemia, and hypertension. Florida officials believe that the care management program has generated modest cost savings along with care improvements.

The Florida program broke significant ground on chronic care management and, learning from the Florida experience, other states followed suit in establishing care management programs. All told, more than 20 states have implemented similar programs.

On the federal level, there have been several legislative and regulatory attempts to implement chronic care management programs in the Medicare population. For some time, Congress has supported the care management concepts employed by managed care organizations and strongly supported the inclusion of managed care into the Medicare program in the “Balanced Budget Act of 1997”, (P.L. 105-33).

The Centers for Medicare and Medicaid Services (CMS) also identified "case management" as a potential tool for improving outcomes and saving costs for the federal Medicare program. The Medicare Case Management Demonstrations, authorized by the Balanced Budget Act (BBA) of 1997, studied the appropriateness of providing case management services to beneficiaries with catastrophic illnesses and high medical costs. 

The “Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000,” (P.L. 106-554) created a demonstration project to display the impact on costs and health outcomes of applying care management to Medicare beneficiaries with diagnosed, advanced-stage congestive heart failure, diabetes, or coronary heart disease. 

Most recently, the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003,” (MMA) established a program aiming to improve quality of care and beneficiary satisfaction through development, testing, evaluation and implementation of Medicare Health Support Organizations (MHSOs), or chronic care improvement programs.
Section 722 of MMA also required Medicare Advantage (MA) plans to have an ongoing quality improvement program designed for the purpose of improving the quality of
care provided to enrollees.  As a part of each quality improvement program, MA organizations must have a chronic care improvement program that monitors and identifies enrollees who have multiple or sufficiently severe chronic conditions that meet criteria established by the organization for participation under the program.

Initial results revealed high interest in the MHS program, and responses from beneficiaries, their caregivers, and physicians have been positive. However, initial reports have not shown savings – only one of the MHSOs is approaching the 5 percent savings target. CMS design flaws, such as focusing only on patients who are older than 85, and data issues have made showing success in the initial phase challenging.

CBO has been somewhat reluctant to score savings for chronic care management programs. A CBO analysis in October 2004 found insufficient evidence to conclude that disease management programs can reduce health spending.  CBO Director Peter Orszag has stated that CMS demonstration and pilot projects are the primary basis for scoring of chronic care management proposals, underscoring the importance of the Medicare Health Support demonstration.

Other studies have been far more positive about care management. A June 2006 MedPAC report discussed care coordination, saying programs should be evaluated for effectiveness and value rather than cost savings. The US Centers for Disease Control and Prevention (CDC) estimates that eliminating poor diet, inactivity and smoking would prevent 80% of heart disease, stroke and Type 2 diabetes, and 40% of cancer.

The private sector has also embraced chronic care management.  Many employers utilize employee wellness programs, health screenings, and fairs to educate employees about their own health and the importance of preventive care.  The number of employers using care management services has also grown.  In fact, Mercer Human Resource Consulting found that, nationally, 67 percent of large employers used care-management programs in 2005, up from 58 percent in 2004.

In 2007, there were numerous legislative efforts to increase wellness and chronic care management, including the introduction of the “Wellness and Prevention Act of 2007”, H.R. 853, which would provide loan payment assistance for preventive medicine physicians; establish a wellness program tax credit for eligible employers equal to 25 percent of the incurred expenses for implementing the wellness program; and establish an individual tax credit of up to $200 for participation in a qualified employer's wellness program.

In addition, the “Healthy Americans Act”, S. 334, would offer premium discounts for participation in wellness programs and for other healthy behaviors; increase reimbursement for "health home"-designated primary care physicians and providers through additional management fees for care coordination services; require the development of a chronic care disease management program designed to provide chronic care disease management to all Medicare beneficiaries with respect to the five most prevalent chronic diseases; and create Chronic Care Education Centers to provide information on chronic disease health care providers.

In growing recognition of the problem of childhood obesity – a contributing factor in chronic disease – the House of Representatives included important nutrition provisions in the “Farm, Nutrition, and Bioenergy Act”, H.R. 2419, which passed the House in July 2007. It included provisions to expand the USDA Snack Program, which helps schools provide healthy snacks to students during after-school activities.  The program will make fresh fruits and vegetables available to 35 elementary and secondary schools in each state, as well as additional elementary and secondary schools in each state in proportion to the student population.  The bill increased funding from $9 million to $70 million in each of fiscal years 2008 through 2012.  The bill also extended the DOD Fresh Fruit and Vegetable program, authorizing $50 million for each of fiscal years 2008 and 2009; and $75 million for each of fiscal years 2010 through 2012.  The bill also established a grant program for nutrition education and promotion to address obesity among low-income Americans. The bill authorized $10 million for each fiscal year until 2012.

The Senate passed its version of the farm bill shortly before the Congress adjourned in December.  The Senate agreed to the program expansions proposed by the House and added its own "Sense of Congress" provisions asking the secretary to support and encourage effective interventions for nutrition education, particularly including coordination of public health approaches and traditional education, to increase the likelihood that recipients of food and nutrition program benefits will choose diets and physical activity practices consistent with the Dietary Guidelines for Americans. The Senate bill also highlighted the importance of public/private partnerships and coordination with other nutrition programs.  The House and Senate continued to work to merge their versions of farm legislation in early 2008.

Provisions in the early drafts of the “No Child Left Behind” (NCLB) reauthorization bill would require the Department of Education to report on food marketing practices on elementary and secondary school campuses. The legislation would also require states to include information about physical education requirements in their comprehensive state education plans. It is likely that amendments may be offered during committee consideration in 2008 to add physical education requirements to the NCLB accountability system.

Numerous coalitions and organizations such as the Partnership to Fight Chronic Disease have sprung up concerning chronic care management and wellness, indicating widespread interest in these issues.

The Future

With chronic care management demonstration projects ongoing, Congress may choose to wait for results before enacting additional legislation on the topic.  However, interest in chronic care management is high, as indicated by the numerous bills pertaining to the topic.

Particularly with health care costs continuing to rise, disease management initiatives offer congressional legislators an attractive way to lower health care spending while improving quality.

Bipartisan support for efforts to reduce obesity is likely to mean that larger bills such as the farm bill and the No Child Left Behind Act will include nutrition provisions.
 
Most of the presidential candidates have addressed chronic care management and wellness as part of their health reform platforms.  For example, Rudy Guiliani promotes healthy lifestyles and proposes that “health insurance should be redefined to cover wellness as well as sickness.”  Hillary Clinton proposes a 7-step strategy to reduce health costs, which includes increased chronic care coordination to improve outcomes.  Such proposals indicate that chronic care management and wellness will continue to be topics of concern in 2008 and beyond.