Tag: chronic care

Why Multi-morbidity Requires Two Health Systems, not One

Jul 16, 2025

By JEREMY SHANE

What’s behind the coming health care reckoning? Most industry leaders have their preferred list of culprits: not us! Left-leaning critics blame large insurers, drug companies, and private equity firms. Take the profit and self-dealing out of health care. Those on the right blame excessive regulation, poorly-designed insurance markets, or limits on individuals’ ability to pick their own coverage. Debates yo-yo between these views in a political stalemate. While the views are diametrically opposed on solutions, they share a belief that financial issues are the root cause of systemic dysfunction. That manipulating how clinicians are paid or insurance is structured can improve health outcomes.

A half century into efforts to fix health care, it is clear that both views are wrong. Americans’ healthspans are shrinking while costs spiral upwards thanks to chronic disease. Progressively worsening illness throughout adulthood eventually explodes in multimorbidity, driving cancer and dementia, and protracted hospitalizations. Clinicians know this, with their well-worn chorus of “if only” laments. If only we could reward prevention instead of treatment. If only we intervened earlier before advanced pathology takes hold. If only clinical care was not fragmented. If only people had a direct stake in their longer-term health. Yet the debate in Washington DC, even shaken up by the MAHA movement’s focus on chronic issues, regresses into an interminable blame game, and conflicting ideas about how Congress or CMS could end the madness.

It is time to break the cycle and say clearly what we know to be scientific fact. It’s impossible to use a system built to solve acute issues to also solve multi-decade, highly variable disease threats. Yet this presumption, that one system can do it all, addressing everything from colds to car crashes to cardiovascular issues to cancer, is so deeply ingrained in our thinking as to escape scrutiny.

It is folly to continue. We need two systems, not one — the first for routine, emergency, and elective treatments and the second to confront long-term, complex challenges. Absent this change it will take far longer than it should, and cost far more, to decipher chronic issues or create economic arrangements that can bring forward the ultimate value of preventing disease.

Resetting Assumptions

It’s illuminating to focus on the scientific drivers of disease rather than the financial after effects. It becomes clear why Medicare Advantage is imploding, and no, it’s not because CMS changed payment rates. Since 2000, the percent of Americans entering Medicare with multimorbidity has jumped by two-thirds, from a quarter of new entrants to over 40%. Software may be eating the world but multimorbidity is eating Medicare, Medicaid, and private insurance, and with it, most Americans’ healthspans.

Most Americans now live a decade more than their grandparents, only to spend all the additional years, and then some, in poorer health.

Lucienne Ide, Rimidi

Feb 22, 2024

Lucie Ide is a physician running Rimidi, a company helping health systems manage patients with chronic conditions. They extract data from EMRs and transfer this into workflow for care teams, predominantly at ACOs and other risk bearing organizations, but also increasingly with FFS groups using RPM to manage those patients. Their current moves are to continue to extend from their first patient group (diabetes) to all types of chronic patients. We chatted about her company, but also about the wider move (or lack of it) to better manage patients in the US system–Matthew Holt

CEO Kuldeep Singh Rajput on Biofourmis’ huge Series D raise

Apr 26, 2022

You may have thought the days of huge digital health rounds were over. Not quite yet! CEO Kuldeep Singh Rajput talks with Matthew Holt about Biofourmis’ $300m Series D raise. They’re in the business of sensors, digital therapeutics and chronic specialty care (cardiology/oncology) and hospital at home. And as if that wasn’t enough, they have a solid plan for both organic & “inorganic” growth!

Will the Uninsured Become Healthier Once They Receive Health Care Coverage?

Apr 9, 2014• 12

By David Orentlicher, MD JD

The Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.

At least that’s the conventional wisdom.

But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.

To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.

How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.

In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.

On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.

However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.

Unpacking the Wyden Chronic Care Bill

Jan 30, 2014• 2

By Billy Wynne

As he ascends to the Chair of the Senate Finance Committee, Senator Ron Wyden’s recent proposal to reform Medicare by improving care for the chronically ill has garnered significant attention and support. Its topline goal of incentivizing integration of care for high-risk patients is resonating with stakeholders across the health care continuum.

In light of its momentum and Senator Wyden’s imminently expanding authority over Federal healthcare programs, we thought it wise to take a closer look at his plan – the “Better Care, Lower Cost Act” (BCLA). What we found is more interesting, ambitious and – potentially – complex than the headlines suggest.

In essence, the BCLA would allow providers (and health plans) to form new entities – labeled Better Care Programs (BCPs) – that receive capitated payments for all Medicare-covered services delivered to their enrollees. The initiative would initially focus on regions of the country with disproportionately high rates of chronic illness and only medically complex patients would be allowed to enroll.

There are a variety of medical protocols that BCPs would be required to adopt, including development of personalized chronic care plans for each enrollee.

If you are hearing echoes of the Accountable Care “movement,” then you are in the right concert hall but listening to a very different symphony. While BCPs share some characteristics with ACOs, they would differ in important ways. A limited number of ACOs in Medicare currently take full(ish) financial risk, but all BCPs would do so, with some risk corridors instituted in the first few years.

Unlike most ACO programs, control groups would be established for purposes of measuring BCP performance. Also – and this is pivotal – BCPs would be required to proactively enroll Medicare beneficiaries, while patients are typically passively attributed to ACOs.

By taking a giant step down the shared savings path, which it travels alongside ACO programs, the BCLA further blurs the line between traditional fee for service and managed care. BCPs would actually be compensated in the same manner as Medicare Advantage plans, the private insurance option in Medicare.