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What are the Highest Chronic Care Conditions in Medicare, Medicare Advantage Plans, and Special Needs Plans?

Six Leadership Readiness Discussion Questions

Payers are developing care models specific to the level of need. For example, on multiple chronic conditions and complex needs, care for homebound patients, and end-of-life care. Or they may focus on specific conditions such as cardiology, oncology, or neurology. There is not a one-size-fits-all care-management strategy. Payers tend to categorize medical conditions by risk.

Risk Categories

For example, the highest risk would be end-of-life and specialty chronic care conditions, such as cancer. The next high risk is complex poly chronic conditions such as diabetes and depression. A rising risk would be primary care treatable conditions such as COPD or hypertension.

Below is key data for fee-for-service Medicare, Medicare Advantage, and Special Needs Plans, which shows that the prevalence of many chronic conditions is similar for enrollees in traditional Medicare and Medicare Advantage, after separating out Special Needs Plans.

Leadership Readiness Discussion Questions

  1. How is your organization reducing the cost of care?
  2. Based on risk, what different technologies are being used?
  3. What changes based on different medical conditions change the approach for care management and care coordination?
  4. How is your partnership creating value to manage specific patient populations?
  5. How can your organization align financial and quality incentives?
  6. What is the engagement strategy of patients for self-care?

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