The solution to America’s trillion-dollar healthcare problem is outside the doctor’s office

By Thomas Ferry
Engooden Health President and CEO

Today, most population health solutions focus on reaching the top 5% of patient acuity. However, many of the next 45% of rising-risk patients in the United States suffer from at least one chronic condition, and when left untreated, these patients are at risk of moving into a high-risk status. Nearly two-thirds of Medicare beneficiaries nationwide live with multiple chronic conditions, incurring over 90% of all Medicare spending. Considering such a large percentage of Americans live with chronic illness, it’s not hard to see the direct need for value-based care between clinical visits, not just at a hospital or physician’s office.

The burden of chronic illness

The Centers for Medicare & Medicaid Services’ (CMS) decision to increase physician reimbursements for chronic care management (CCM) in 2022 reflects an increased need to broaden care beyond clinical settings. CMS understands CCM is a “critical component” of healthcare and that it enables patients with chronic conditions to achieve better health outcomes. While physicians are responsible for 100% of patient health outcomes, the American Hospital Association reports clinical care only accounts for 20% of overall health. This means that the majority of the influence on patient health happens outside of the doctor’s office and inside patient homes and communities.

Reaching rising risk patients

Without consistent, trust-based engagements between clinical office visits, rising-risk patients may have difficulty managing their chronic conditions between doctor’s visits. These patients are often unaware, reluctant, or incapable of accessing the necessary care to avoid becoming high-risk. For some patients, this inability comes from frustration with an increasingly complex healthcare system. Others, as too often happens, are ignored and disenfranchised by it.

An evaluation of chronic care management or chronic disease management in 2017 revealed that these services resulted in better adherence to treatment recommendations and improved health outcomes for patients. Patients who embrace healthier behaviors are more likely to improve their conditions, which is why chronic disease management services are so important.

The value of a human touch

Some patients need a simple reminder to pick up their prescriptions. Others, particularly the elderly, need to feel a genuine human connection. Whatever it may be, programs that regularly engage patients outside of clinical environments are more likely to influence patient behavior, help them manage their diseases and allow them to save money while they do it. Enrolling in a chronic disease management program means clients only pay a copay, and it reduces the potential for an emergency room visit, which can cost a patient thousands of dollars. Additionally, regular touchpoints between clinical visits grant providers a complete view of a patient's health, including socioeconomic factors and health behaviors that often go undetected and significantly influence their overall wellbeing. Without the context of these social determinants of health, doctors cannot create better, more consistent person-centered primary care.

How Engooden helps

Our team of care navigators work closely with providers to fill primary gaps and prevent rising-risk patients from becoming high-risk by providing consistent outreach and custom care plans at scale. Engooden care navigators are compassionate, highly skilled problem solvers who invest in long-term patient relationships through direct monthly outreach. Care navigators develop deep, trusting and emotional connections with patients, which allows us to uncover care gaps, insights, and opportunities for interventions that are difficult to discover in a short office visit.

Using our proprietary technology, we’re able to continuously analyze EHR records for chronic disease management patients and create actionable insights that allow our care navigators to intervene with the right patients at the right time. Engooden’s approach ensures patients with chronic conditions are being cared for between traditional office visits, lowering the risk of acute medical events and creating healthier lifestyles for patients.