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How the demands of chronic condition management and an aging population are driving transformative care models

Amid the clinical and financial transformation in healthcare, one area that continues to elude health plans is the appropriate management of care for members with multiple chronic conditions (MCCs). According to a HealthScape analysis, members with six or more chronic conditions are 4x as expensive as the average Medicare beneficiary.

Health plans struggle with managing this population due to site of care challenges, fragmented care coordination across specialists and facilities, financial misalignment and a lack of clinical competencies for complex chronic care.

As a result, health plans and health systems are increasingly investing in custom programs to manage MCC members. Key components of an integrated model include:



A patient-centric, tailored model of care

Advanced technology and analytics

Aligned risk-based payment

Specialized expertise



In recent years, a few companies have emerged that have deployed distinct approaches to manage MCC patients. These approaches are differentiated by care delivery setting.


Customizing the Clinic-Based Model for MCC PatientsDelivering In-Home Care for MCC Patients
Iora Health – Interdisciplinary team model offering medical care for a broad population of complex patients. Iora assumes full risk, leveraging providers and health coaches as primary connection with patients.Independence at Home – The Center for Medicare and Medicaid Innovation’s (CMMI) test program to deliver primary care via interdisciplinary teams to MCC Medicare beneficiaries.
ElderPAC – Pennsylvania-based in-home primary care model with community-based services through Medicare and Medicaid Programs.
Care Management Pus (Intermountain Healthcare) – This program embeds care managers in PCP offices to augment care for complex members.MedStar – Medical house call program offering team-based primary care to eligible patients in Washington D.C. available 24/7.
VA Home-Based Primary Care – VA-led primary care program to chronically ill veterans providing integrated health in their homes.

HealthScape’s deep dive into Landmark Health, a mobile provider group focused on in-home care delivery to the chronically ill, demonstrates how it has adopted the key elements of an effective, integrated model.

In this whitepaper, HealthScape lays out a four-step diagnostic to understand a health plan’s chronic care management opportunity, which can lead to significant Medical Loss Ratio (MLR) improvement. Consider following this roadmap to unlock your health plan’s potential.



Do you need an evaluation of members with MCCs and new or existing models for chronic care delivery? Contact Michelle Werr at (630) 546-5044 or mwerr@healthscape.com to discuss HealthScape’s capabilities.