What are chronic diseases?
According to the CDC, Chronic diseases are defined as “conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both. These include diseases like heart disease, stroke, cancer, diabetes, obesity, arthritis, Alzheimer’s disease, epilepsy and tooth decay.
What is chronic disease management?
Chronic care management aims to improve the quality of life of patients suffering from such diseases by preventing or minimizing their effects. This is done through screenings, check-ups, monitoring, coordinating treatment, and patient education.
Unfortunately, despite the ability to prevent and control such conditions, chronic diseases still place an immense burden on healthcare systems and result in overwhelming costs and mortality rates. In fact, chronic diseases are the leading causes of death and disability in the United States, and are among the leading drivers of healthcare costs. Moreover, chronic diseases account for nearly 90% of the U.S.’s $4.1 trillion in annual health care costs and “are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs.”
A number of barriers, some in relation to the nature of chronic diseases and others in relation to challenges in the healthcare system, make effective chronic disease management difficult to achieve.
Barriers to chronic disease management
- Multimorbidity– In most cases, chronic diseases tend to occur alongside additional health issues and diseases. In fact, studies show that 50-70% of chronic-disease patients have more than one chronic condition as a result of both disease biology and because many diseases share common underlying risk factors. These risk factors include obesity, genetics, poor diet, exercise, etc. So while the diseases progress, patients are also likely to develop additional health issues, making them more difficult to manage.
- Habits and behaviors– As mentioned above, most of the risk-factors underlying chronic disease progression are related to lifestyles and behaviors. These include poor diets, a lack of exercise, smoking, substance abuse, and a lack of medication adherence. Making changes to such lifestyles requires consistent effort over time, which often proves difficult due to factors like socioeconomic status, physical environment, social support networks, and access to care, as well as the psychological challenges involved.
- Social determinants of health– studies have shown that social determinants of health like lower socioeconomic status, less access to care, living in particular locations, and belonging to a specific race or ethnic minority are associated with a greater risk of developing a chronic disease and poorer health outcomes.
- Health literacy– Often, patients with chronic diseases lack proper understanding of what constitutes the right frequency, intensity and duration of exercise or how to make appropriate adjustments to their diet and incorporate these changes into their lives.
Challenges facing payers and providers
In addition to the challenges associated with the nature of chronic diseases, a variety of factors within healthcare systems and workflows complicate the treatment process and reduce the likelihood of their success. Some of these factors include:
- Financial and opportunity costs for providers – most providers and healthcare institutions are already overbooked and understaffed. Given their limited time and resources, they typically don’t have time to direct bandwidth to patient monitoring, follow up, and care, which are critical to chronic disease management, as they present them with financial and opportunity costs.
- Siloed workflows and tools- Given the complexity of chronic diseases and the likelihood of multimorbidity, interaction between a number of stakeholders, including patients, physicians, pharmacists and any health coaches or social workers is needed. However, because tools and workflows are not generally optimized to accommodate such communication, chronic diseases are typically addressed in isolation which reduces the likelihood of successful treatment.
- Dearth of data- for chronic disease management to be most effective, it ought to address the individual needs of the patient based on their lifestyles, habits, and abilities. To best understand these patients and providers would need to support “granular tracking of key biomarkers, self-reported measures of pain and mood, patient adherence to medication and lifestyle changes” so that providers can understand when circumstances change and intervene when necessary.
How digital tools are improving chronic disease management
In the past few years, a number of programs and technologies aiming to alleviate some of these challenges have emerged to provide patients with more control over disease management and enable providers to meet their patients where they are. Some of these include:
Telehealth- Telehealth services have made it easier for patients with low access to care to overcome the challenges associated with travel to clinics, including cost, time off work, and lack of transportation for people in rural areas. The continued growth of telehealth will enable patients to monitor and follow up on progress, and access care before their disease is beyond control.
Remote health monitoring that integrates with provider tools – this enables patients to take more control over their disease management while also ensuring that providers get the data they need to help patients understand their problems and tackle them effectively.
Incentivizing behavior change – these include wellness programs and apps that use insights from behavioral science to motivate patients to change their behaviors. One example is Vitality UK, which rewards clients for achieving specific, measurable goals and has proven to increase physical activity by up to 34%.
Connected care workflows – services that integrate workflows between physicians, patients, and other stakeholders in the patients disease like pharmacies and insurance, will enable patients to navigate processes with greater ease, will enable providers greater visibility into the patient’s health, and will allow providers to work together with specialists to tackle the issues associated with multimorbidity.
Predictive analytics – as granular tracking of health data becomes ubiquitous, platforms that leverage this data to support preventive care will help curb the damage of chronic diseases. Using data to predict which patients are likely to develop chronic diseases or to identify care gaps will enable both patients and providers to make the changes necessary to prevent disease onset or progression in time.
Health literacy– wellness apps that help educate patients and remind them how often to exercise, which types of foods to eat, what kind of nutrients they need, enable them to track their health data and learn their vital signs and what they mean will help increase health literacy and help patients understand how they can improve their health.
By meeting patients where they are, incentivizing long-term behavior change, filling in gaps in health literacy, connecting care workflows, and supporting early detection of risk, digital tools present great promise for the future of chronic disease management. Payers, providers and digital innovators that implement such tools can help ease the costs of chronic disease management, reduce inequities in health and help patients worldwide manage their diseases.
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