If we as a nation want to do something to improve health and well-being and control the cost of care, we must tackle the problem of chronic diseases. Over the course of their lives, about half of all Americans will suffer from chronic conditions such as heart disease, diabetes, obesity, and depression. In addition to causing illness, disability, loss of employment, and death, chronic conditions account for about 90 percent of the nation’s $4.5 trillion in annual health care expenditures. Of the 68 million people who use Medicare, more than 95 percent have at least one chronic condition, and almost half have four or more. Many Medicaid beneficiaries also experience higher-than-average rates of chronic conditions.
Decades of experience tell us that tackling chronic diseases is complex and difficult—but not insurmountable. Mathematica delivers solutions that optimize chronic disease prevention and management programs and policies to ensure efficiency, cost savings, and measurable impact.
Harnessing real-world data and analytics to effectively combat chronic disease
Our analytics tools use real-world data to help public and private sector clients easily identify and intervene with patients with chronic conditions who are at risk of experiencing severe health complications. We co-designed a platform that brings together data from Medicare, Medicaid, hospitals, labs, physician offices, and commercial payers to help medical providers identify and intervene with patients at risk of developing chronic kidney disease, an invisible epidemic that is a growing cause of dialysis, kidney transplant, and death in the United States.
We also work with clients such as the Minnesota Department of Health to use all-payer claims data to estimate and project the costs of chronic conditions. Together, we’re uncovering insights into how conditions such as obesity contribute to poor health and increased healthcare costs. Our tools help policymakers, providers, employers, public health organizations, and health plans to identify opportunities to make getting care in Minnesota more effective and efficient.
Developing reliable measures to hold payers accountable for cost-effective care that promotes health
Medicare and Medicaid need reliable measures (1) of how care is (or isn’t) coordinated across providers, (2) whether providers are using preventive services effectively, and (3) whether patients are able to avoid costly and often unnecessary services such as emergency room visits. These measures enable payers and providers to target interventions, assess effectiveness, and stay accountable.
Mathematica and partners developed a set of measures focused on Medicaid beneficiaries with chronic or high-cost conditions for the Centers for Medicare & Medicaid Services (CMS). We help state, federal, and private payers ensure high-quality and effective care is delivered to their beneficiaries by measuring if individuals who have substance use disorders or co-occurring physical and mental health needs receive appropriate medications and follow-up care—and by examining emergency department and inpatient hospital admissions use among people with two more chronic conditions.
We also worked with the U.S. Department of Health and Human Services and a broad range of interested parties to develop measures that states and health plans use to monitor whether people with serious mental illnesses receive preventive physical health care. State Medicaid programs and health systems can tie provider payments to performance on these measures to reduce the high rates of chronic physical health conditions among people with serious mental illness.
Finding what works to prevent chronic disease and provide better care
Healthcare payers use various interventions and financial incentives to help prevent chronic disease and improve care for patients with complex conditions. But understanding which interventions work will inform broader adoption of best practices. Mathematica and partners studied CMS’s Million Hearts Cardiovascular Disease Risk Reduction Model, which paid providers to measure their patient’s risk of a heart attack or stroke so they could identify and treat high- and medium-risk Medicare beneficiaries. Our evaluation showed the approach reduced first-time heart attacks and stroke or death—all without increasing care costs. CMS used lessons from Million Hearts to establish a new rule in the Medicare Physician Fee Schedule that supports payment for atherosclerotic cardiovascular disease risk assessment and risk management services that increase access to the lifesaving interventions tested in the model.
Our evaluation of CMS’s Comprehensive Primary Care Plus Model found that increasing financial support to improve primary care delivery, care coordination, care management, and behavioral health integration can result in the prevention of chronic conditions and improve the management of patients with complex health conditions. The approach led to a reduction in emergency department visits, inpatient hospitalizations, and acute inpatient spending. CMS is testing new value-based advanced primary care payment models based on these lessons and updated the Medicare Physician Fee Schedule to support payment for a new set of advanced primary care management services.
Working with states to reduce chronic disease and deliver effective, efficient care
When states need to understand best practices in care management programs and how to help high-need, high-cost patients, Mathematica is there. Mathematica provides technical assistance and support to states and CMS through the Integrated Care Resource Center to improve care for individuals dually enrolled in Medicare and Medicaid—a population of people who are over the age of 65 or under 65 with disabilities who often face significant health challenges and have to navigate two separate, siloed health insurance systems.
We also work with Delaware’s Division of Public Health to reduce adult and childhood obesity and other chronic conditions by supporting community partners with planning, implementing, and evaluating interventions to promote healthy lifestyles. We helped develop a workplace wellness policy and toolkit and assisted the state in collecting and analyzing data to understand the impact of chronic disease in Delaware. This comprehensive approach is helping Delaware continue to advance chronic disease prevention and management statewide.
Patients with complex chronic conditions have a variety of needs, and there’s no one-size-fits-all solution to address them. Having the right data—and expertise to put that data to use—can ensure effective and efficient care for the millions of Americans facing chronic disease. And it can help ensure our healthcare system promotes health to prevent chronic conditions in the first place. Where efficiency meets impact, we can make progress together.
