Value-based Care Must Evolve to Manage Multiple Chronic Conditions

A disease-centered approach often fails in value-based care. Active participation is vital to provider success.

The Multimorbidity Challenge in Value-Based Care

Value-based care models have transformed healthcare delivery by shifting focus from volume to value. However, as these models mature, a critical limitation has emerged: most are designed around single disease states, while the reality of patient populations—especially Medicare beneficiaries—is far more complex.

The Scale of Multimorbidity

The statistics tell a compelling story:

• 68% of Medicare beneficiaries have two or more chronic conditions
• 36% have four or more chronic conditions
• The average Medicare beneficiary with multiple chronic conditions sees 7 different physicians annually

These patients account for:

• 93% of Medicare spending
• 98% of all hospital readmissions
• 76% of all physician visits

Yet most value-based care programs remain siloed by disease state, creating fragmentation rather than integration.

The Limitations of Disease-Centered Value-Based Models

Traditional value-based care models often focus on specific conditions like diabetes, COPD, or heart failure. While this approach has merit for specialized care, it creates significant challenges:

1. Care Fragmentation

When patients participate in multiple condition-specific programs, they often receive:

• Contradictory advice from different care teams
• Duplicate services and assessments
• Overwhelming and sometimes conflicting care plans
• Multiple care managers contacting them

One patient described it as "having five different people calling me every week, each asking about a different part of my body, but nobody seeing the whole me."

2. Provider Burden

Providers face equally challenging fragmentation:

• Managing patients across multiple value-based programs
• Navigating different quality metrics and reporting requirements
• Reconciling conflicting clinical guidelines
• Coordinating with numerous care management teams

A primary care physician noted: "I have patients in diabetes, COPD, and heart failure programs simultaneously. Each program has different care managers, different portals, and different metrics. It's impossible to keep track of it all."

3. Misaligned Incentives

Disease-specific programs can create perverse incentives:

• Focus on conditions with the highest reimbursement rather than patient needs
• "Cherry-picking" patients with single conditions
• Neglecting conditions outside program parameters
• Difficulty attributing outcomes to specific interventions

The Path Forward: Patient-Centered Multimorbidity Management

Evolving value-based care requires a fundamental shift from disease-centered to patient-centered approaches. This transformation involves several key elements:

1. Integrated Care Management

Successful models are implementing:

• Single care manager coordinating all conditions
• Unified care plans addressing all comorbidities
• Integrated risk stratification across conditions
• Holistic needs assessments beyond clinical factors

2. Flexible Quality Metrics

Progressive programs are adopting:

• Patient-centered outcome measures
• Weighted quality metrics based on condition burden
• Cross-condition outcome measures (e.g., functional status)
• Patient-reported outcome measures (PROMs)

3. Technology-Enabled Coordination

Essential technological capabilities include:

• Unified patient records across conditions
• Intelligent care gap identification
• Cross-condition decision support
• Integrated communication platforms

4. Aligned Financial Incentives

Financial models must evolve to include:

• Global capitation with risk adjustment for multimorbidity
• Shared savings across condition categories
• Bundled payments for common comorbidity clusters
• Care coordination payments for complex patients

Case Studies: Successful Multimorbidity Management

Case Study 1: Integrated ACO Approach

A Midwestern ACO transformed its approach to complex patients by:

• Implementing a "complexity score" beyond HCC
• Assigning a single care coordinator to patients with 3+ conditions
• Creating unified care plans addressing all conditions
• Developing cross-condition pathways for common comorbidity clusters

Results:

• 32% reduction in hospital admissions
• 28% decrease in ED visits
• 22% improvement in patient satisfaction
• 18% reduction in total cost of care

Case Study 2: Primary Care Transformation

A primary care network in the Northeast implemented:

• Team-based care with dedicated complex care managers
• Unified technology platform across all conditions
• Standardized assessment tools for multimorbidity
• Flexible visit scheduling based on complexity

Results:

• 40% reduction in care fragmentation
• 35% improvement in medication adherence
• 25% decrease in specialist referrals
• 20% increase in provider satisfaction

Implementation Roadmap

Organizations looking to evolve their value-based care approach should consider this phased implementation:

Phase 1: Assessment (1-3 months)

• Analyze population for multimorbidity patterns
• Map current care management processes
• Identify fragmentation points
• Assess technology capabilities

Phase 2: Design (2-4 months)

• Develop integrated care management model
• Create cross-condition pathways
• Design unified documentation approach
• Establish multimorbidity quality metrics

Phase 3: Implementation (3-6 months)

• Train care teams on integrated approach
• Deploy technology enhancements
• Implement new workflows
• Establish baseline measurements

Phase 4: Optimization (Ongoing)

• Monitor outcomes across conditions
• Refine approaches based on data
• Expand to additional comorbidity clusters
• Continuously improve integration

Conclusion: The Imperative for Evolution

Value-based care has made tremendous strides in improving quality and reducing costs. However, its continued success depends on evolving beyond single-disease models to address the reality of multimorbidity.

Organizations that embrace this evolution will be positioned to:

• Deliver truly patient-centered care
• Reduce fragmentation and provider burden
• Achieve sustainable cost reductions
• Improve outcomes for the most complex patients

The future of value-based care isn't in perfecting disease-specific programs but in transcending them to create truly integrated, patient-centered care models that address the whole person, not just their individual conditions.