In response, chronic disease management programs have proliferated over the past decade in the private sector and are common in Medicaid and Medicare Advantage programs. But they are notably absent in traditional fee-for-service Medicare—a crucial gap, given that 81 percent of Medicare beneficiaries are enrolled in traditional fee-for-service Medicare and account for about 79 percent of the program’s overall healthcare spending (Orszag, 2007). The Medicare program’s fragmented benefit design and reimbursement policies discourage care coordination and disease management. At the same time, these conditions present opportunities for prevention, better care, and long-run cost savings (CBO, 2005). The medical home concept developed by the National Committee on Quality Assurance has attracted attention and interest as a potential solution, but it has limited scalability among the 83 percent of U.S. medical practices that comprise just one or two physicians (GAO, 2008; Sokol et al., 2005). An alternative (and complementary) approach is required to scale coordinated care nationwide. CHTs working with primary care practices, patients, and their families apply key functions and processes used by larger successful physician group practices and integrated plans and replicate them in less resourced and organized settings (Figure 12-1). CHTs include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. These trained resources already exist in many communities, working for home health agencies, hospitals, health plans, and community-based health organizations.

Evidence of Effectiveness and Cost Savings

Research supports the clinical and economic benefits of comprehensive, multidisciplinary, individualized interventions targeted to medically complex patients. Evidence-based components of CHT practice elements are listed in Table 12-2.

CHTs should include a number of critical foci in order to better address current healthcare needs and control financial costs. Four are discussed below.

Prevention services Taking lessons from the large-scale, randomized diabetes prevention program (DPP) (Department of Health and Human Services, 2001; Knowler et al., 2002; Wing et al., 2004)1 trials, group-based DPP protocols have been administered in community settings and have produced impressive outcomes, reducing disease incidence at a fraction of


At the time of the Department of Health and Human Services press release, the cost of the DPP was reported to be $174.3 million for 3,234 participants, and average cost of $53,896.10.

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