Chronic Care Model

Background

During the 1970s and 1980s, with U.S. healthcare costs regularly doubling the rate of inflation, many proponents of reforming the nation's healthcare system turned to managed care. A centerpiece of healthcare expenditure increases during these decades, above and beyond the aging of the population, was the rapid increase in the “intensity” of care, particularly hospital care for older patients with chronic illnesses. Yet despite the increase in surgical procedures and hospital-based specialty care, health services researchers were simultaneously producing ample documentation of major quality problems in basic chronic disease care for all Americans.

Early policy responses included the original federal health maintenance organization (HMO) acts of 1973 and 1976, which aimed at the creation of large integrated healthcare delivery systems that combined hospital and outpatient care. Such systems offered financial incentives, such as capitation (a fixed fee per year) reimbursement for a defined population of enrolled patients, to emphasize preventive health maintenance and avoidance of preventable exacerbations of chronic diseases. Because about 10% of the sickest patients generate over two thirds of all healthcare costs, there is a major financial incentive for prepaid delivery systems to better manage their highest-risk enrollees. It was hoped that capitated payment systems would initiate a new prevention and health promotion paradigm that could reverse the often perverse financial incentives of the fee-for-service system, which restricted reimbursement to treatment of acute, urgent medical problems.

Although the HMO movement failed to transform the nation's healthcare, several large integrated systems, such as Group Health Cooperative, Kaiser-Permanente Northern California, and the Veterans Health Administration (VHA), did develop innovative disease management approaches to providing coordinated chronic disease care. These organizations were pioneers in adopting medical management information systems that could track utilization of care across multiple episodes of illness and provide computerized clinical guideline reminders and decision support to physicians. In addition, these organizations were able to offer multidisciplinary team-based care and proactive telephone follow-up of patients—services that are generally not reimbursed in traditional fee-for-service practice settings. It was from these successful experiments in redesign of primary care for chronically ill patients that Wagner and his colleagues distilled the CCM.

Basic Principles of the Model

The CCM was developed to capitalize on the best features of primary care, defined by the Institute of Medicine (IOM) as the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing within the context of family and community. The CCM seeks to go beyond managed-care gatekeeper models that attempt to reduce unnecessary care (and costs) by requiring specialty referrals from primary-care physicians. Instead, recognizing that most chronically ill patients receive the bulk of their care from primary-care physicians, and that the majority of them have multiple disease conditions, the CCM advocates efficient integration of specialty care into clinical case management while preserving a “whole”-patient perspective. Six synergistic “ingredients” of the model were distilled from evaluations of successful disease management and quality improvement efforts during the 1990s. Each is discussed below.

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