How Care of Chronic Conditions Would Improve
Under Patient-Centered Payment

Ms. Adams is overweight. Because of her work and travel schedule, she does not exercise regularly and has a poor diet. Recently, she has been feeling both hungry and tired more often.

Care Delivery
Under Current Payment Systems

Care Delivery
Under Patient-Centered Payment

Ms. Adams attributes her hunger and fatigue to working too hard. She feels she is too busy to schedule a doctor’s appointment. Moreover, based on the experience she had during her last primary care visit, she does not feel it would be worth the time.

Ms. Adams has been enrolled with a primary care practice for wellness care, and the primary care practice has encouraged her to get regular blood tests. They are alerted when her most recent HbA1c test exceeds the threshold for diabetes. The staff of the practice contact her to schedule a visit with the physician. They work with Ms. Adams to schedule the visit at a time that does not interfere with her work and travel schedule.

Because Ms. Adams is not receiving any regular wellness care or testing, no one realizes that she has developed diabetes, and she receives no medications that could help to control it.

The physician repeats the HbA1c test and performs some additional tests, examines Ms. Adams, and based on the tests and examinations, he diagnoses her as having developed Type 2 diabetes. The physician explains the need to take appropriate steps to treat Ms. Adams’s condition and the long-term complications that can result from failure to treat diabetes properly. He talks with Ms. Adams about the different options for treatment and develops a treatment plan that both he and Ms. Adams feel is appropriate and feasible for her.

The physician encourages Ms. Adams to enroll with the practice for chronic condition management services and describes the kinds of education and proactive care that the practice will be able to offer if she does. He says there is no additional cost to her to do this under her health insurance plan, and she can “unenroll” any time she wants. The physician tells Ms. Adams that he and the other staff at the primary care practice are experienced in managing the care of patients like her and they are committed to ensure that she receives all of the most appropriate, evidence-based care in order to achieve the best outcomes. He assures her that he will consult with an endocrinologist or other specialists if necessary, and that if he feels she needs more specialized care, he will refer her to an appropriate specialist. Ms. Adams is impressed with the care she has already been receiving and she agrees to also enroll for chronic care management services for her diabetes.

Ms. Adams continues to gain weight and her fatigue worsens. After a number of months, her family urges her to see her primary care physician, so she makes an appointment. The physician suspects she may have diabetes but he needs a blood test to confirm that. He orders a blood test and tells Ms. Adams she can go to any hospital or laboratory to have the test performed.

Ms. Adams does not get the blood test immediately and no one from the primary care practice calls to remind her. Since her symptoms have not improved, her family convinces her to schedule the test at a local laboratory, and she has the test performed.

The primary care practice notifies Ms. Adams that her test results are problematic and that she should schedule another appointment with the physician. Ms. Adams delays scheduling the appointment because she is concerned about what the physician will tell her. Her family urges her to call and make an appointment, and when she finally does, the primary care practice schedules a visit for the following week.

Immediately after the physician finishes his discussion with Ms. Adams, the nurse who has been helping her with wellness care talks with her about her new treatment plan for diabetes and whether she will need any assistance in following it. For example, the nurse will determine if Ms. Adams can afford the medications the physician has prescribed, and if not, he will look for sources of financial assistance and/or talk with the physician about alternative types of medications that would be more affordable.

The nurse tells Ms. Adams that the primary care practice wants to be proactive about ensuring that her treatment plan is working effectively for her and he determines the best methods and times to contact Ms. Adams. He also explains potential complications of the condition and encourages Ms. Adams to contact the practice immediately if any of those complications occur, rather than waiting and potentially causing even more severe problems to occur.

When Ms. Adams finally sees the primary care physician, he diagnoses her with diabetes and prescribes medications for her to take. Because she has delayed seeking care for so long, her HbA1c levels are very high, and so the physician orders two medications in an effort to control it. The physician asks her to schedule a follow up visit in a month.

Ms. Adams gets the prescriptions filled, but experiences dizziness and other side effects which make it difficult for her to work and travel, so she doesn’t take the medications as prescribed.

When she has her follow-up visit with the physician, her blood sugar has worsened rather than improved, so the physician prescribes a third medication. Ms. Adams mentions her concerns about the dizziness and other side effects, and the physician tells her that it is important for her to get her HbA1c under control and that some side effects are unavoidable.

The nurse and other practice staff follow up with Ms. Adams multiple times during the initial month following her diagnosis to ensure that she has obtained the medications needed for her treatment plan and to address any side effects or difficulties she is facing in taking them. Once any initial problems have been resolved, the nurse and other practice staff continue to monitor Ms. Adams’s condition, but less intensively than during the initial month.

Ms. Adams gets the additional prescription filled, but she skips doses of the medications frequently because of the side effects. Her HbA1c decreases somewhat, but remains in a problematic range.

Because Ms. Adams’s diabetes was identified early, her HbA1c levels are not very high, she only needs to take one medication when she begins treatment, and the primary care practice is able to help her get her blood sugar under control with a combination of diet, exercise, and medication that she feels is feasible for her.

The primary care practice bills Ms. Adams’s health insurance plan for the two office visits. Because Ms. Adams has been diagnosed with diabetes, her HbA1c scores are included when her health plan calculates a diabetes quality measure. Although Ms. Adams and a number of the other patients in the practice with diabetes have HbA1c levels that are too high, most primary care practices have a similar percentage of patients with high HbA1c levels, so the primary care practice is paid the standard amount for the visits with Ms. Adams and other patients.

The primary care practice bills Ms. Adams’s health insurance plan each month for a Chronic Condition Management Payment in addition to a monthly Wellness Care Payment, and the practice receives a higher Chronic Condition Management Payment during the initial month of services when the treatment plan is first being developed and implemented. The primary care practice is eligible to receive the payment each month because (1) it is providing Ms. Adams with all appropriate, evidence-based services for diabetes, and (2) Ms. Adams remains enrolled with the practice for chronic condition management since she values the high-quality, patient-centered care and proactive services it is providing her.