12/11/2013 12:56 pm ET Updated Feb 10, 2014

No 'Magic Pill' for Helping Patients Manage Chronic Illness

As millions of uninsured Americans prepare to gain health coverage in 2014, and hospitals, providers and medical groups begin pioneering new care models introduced by the Affordable Care Act (ACA), the effects of health reform are starting to be felt in every corner and community of the United States. It's all to achieve the triple aim: improving the health of populations, improving the delivery of patient care, and reducing our nation's health care spending. But, before we can truly attain these ambitious goals, there is absolutely one thing that must happen: We must revolutionize the way we care for patients. We must focus on patient engagement.

The Elephant in the Room

Today in America, one in four people -- of all ages -- suffers from multiple chronic health conditions and accounts for more than two-thirds of all health care spending. In other words, for every health care dollar spent in the United States, roughly 75 cents is attributable to chronic illness. Data on aging Baby Boomers are equally concerning. More than 68 percent of all Medicare beneficiaries today are living with two or more chronic health conditions, comprising the vast majority of all Medicare spending. These numbers reflect people who could be living better, healthier lives. We can do better.

One of the best places to start is by re-examining how care plans for patients with chronic illnesses are designed, but more importantly, how they are administered. Considering that adherence to care plans among patients suffering chronic diseases averages only 50 percent in developed countries, according to the World Health Organization, there is a massive opportunity for improvement.

The first step is accepting that there is no "magic pill" to fix the problem. No single strategy will work for every patient. Designing effective care plans for patients, much like their chronic health issues, is inherently complex.

Doctor's Orders

For patients suffering from Type 2 diabetes, for example, treatment often involves a comprehensive care plan, including a regimen of drug therapies and lifestyle changes such as diet and exercise. For many years the dominant practice has been simply telling patients what they need to do, and letting them determine how to act on that information. Any physician -- or person trying to adopt a healthier lifestyle for that matter -- will tell you that this approach is lacking.

Moreover, many patients today are often put into the position of having to coordinate care for their chronic health condition (securing authorizations, scheduling and managing appointments and tests, sharing medical information, etc.). This is especially challenging for patients with multiple chronic health conditions, which can require spending hours every week just to get all of their care specialists on the same page.

From our own experience delivering care to large populations of patients with diabetes and other chronic conditions, it is clear that simply providing patients with information is not enough. Active and enduring engagement between patient and provider is essential to achieving better health outcomes. Equally important is helping patients with the coordination of their care, and in the truest sense, partnering with the patient throughout their care plan. Within our care delivery network, for example, an affiliate medical group called High Desert Medical Group has implemented a high-touch engagement program for patients with chronic illness.

Called Care Coaching, the program assigns each patient a "Care Coach," who collaborates with them to identify aspects of managing their health condition for which they would like assistance. For example, many diabetes patients ask for help with their diet. To support the diet change, the Care Coach calls the patient weekly to provide encouragement, answer questions, and help the patient to set goals. Care Coaches also take on the role of care coordinator, assisting the patient with scheduling and completing routine preventive care procedures, such as eye exams and lipid screenings. Our data indicates that patients actively engaged in Care Coaching see a one- to three-point improvement in their hemoglobin A1C labs -- a key measurement of health in diabetes patients.

Always On

The good news is that new programs like Care Coaching are emerging every day, providing a much needed answer to the traditional, passive care model that has existed for patients with chronic illness. Additionally, in recent years, another exciting development has come from the explosion of mobile technologies and personal health devices. We now live in an era where a majority of smartphone users use their phone to access medical information, and one in five has a health app downloaded on their phone. These technologies hold great potential to further empower patients with managing their chronic illnesses, build even stronger relationships between patients and their providers, and assist in the coordination of care.

There is no magic pill for managing chronic illness. It requires a variety of strategies, but the most important factor is patient engagement. Care delivery that puts the patient into focus, and embraces new and innovative ways of engaging patients in their treatment will help us realize the triple aim of health reform.

The Heritage Provider Network is a sponsor of the Merck | Heritage Provider Network Innovation Challenge, which called on entrepreneurs, data scientists, designers, health care providers, and big thinkers to create the products or services that will support patients with diabetes and/or heart disease in adhering to their care plans and ultimately improving health.


This blog series is produced in partnership with Health Data Challenges, creators of The Health Data Challenge Series, a formal initiative of the Health Data Consortium, powered by Luminary Labs. The platform seeks to foster the use of data to drive innovation that will ultimately transform health and health care through high-stakes innovation challenges. Learn more at