Is the Chronic Care Model (CCM) a cost-effective mechanism for improving the quality of life for persons living with diabetes mellitus and HIV?

According to the Disease Management Association of America, an estimated $1Billion was spent in 1999 to develop and implement disease management programmes. Despite the significant investment, evidence supporting the effectiveness of disease management is insubstantial. Weingarten et al find that, although a limited number of published trials have documented the effectiveness of disease management in specific situations, uncertainty remains about its overall value. 

Many studies on the long-term management of diabetes involve highly motivated practices that focus on a single chronic condition. Here again there is insufficient proof that requisite practice changes are sustainable, and/or that they spread to the care of other illnesses or less motivated practices. Thus, despite a plethora of studies, no empirical conclusion could be reached about the effectiveness of the CCM, (or any other chronic disease management mechanism), in improving the quality of patients’ lives. Similarly, health cost savings due to CCM interventions could not be empirically determined. The reasons, which have been discussed at length in the section on “Methodology,” are not unique to diabetes, but hold true for HIV and other chronic diseases. 

Part of the reason may be that the CCM is not a discrete, immediately replicable intervention. Rather, it is a framework within which health care practices translate general ideas for change into specific, often locally distinctive applications. As a result, the changes associated with a particular CCM element may vary from organization to organization. In addition, evidence of the CCM’s cost-effectiveness is nascent, and “…more research is needed to understand the costs and benefits to practices, payers, and patients” [Coleman et al. 81]. Such research would be improved through the use of a standardized categorization of the changes made [Coleman et al. 82] 

Health care organizations must expend considerable resources and effort to transform their practices in accordance with the CCM. Although in theory such transformation should lead to improved patient care and outcomes, in reality the impact on health care costs and revenues remains uncertain and will vary by condition. An additional challenge arises from the conflict between CCM and the existing compensation structure. The CCM recommends services and modes of delivery that are generally poorly reimbursed or not reimbursed at all in most fee-for-service schemes [Coleman et al. 82] 

Many characteristics of the current health care system in the United States impede efficient delivery of high-quality care of patients with chronic disease or who are at risk for developing a chronic disease. A fundamental issue is a health care system designed to deliver ad hoc episodic care to patients with acute illness or acute manifestations of chronic illness. Acute care hospitals still dominate the organizational structure of the health care system and account for over 30% of health care expenditures. Many physicians’ practices are largely organized in relationship to hospitals on the basis of employment or staff privileges. We would expect practice patterns for these physicians to be highly influenced by hospital dominance of the delivery system for the foreseeable future. In terms of community practice – an important aspect of the CCM model – approximately 40% of physicians are sole practitioners. Consequently, these community practices lack the integrative capacity that is essential to the CCM’s effectiveness. Conversely, they are fragmented organizationally; have no structural basis through which to deliver coordinated care: no common medical records system or methodology to track disease progress together. 

On the weight of the evidence, it would be difficult to assert that chronic disease management has a substantive positive impact either in quality of life or economic terms. Certainly both the organizational and economic structure of the health care system militate against key tenets of the CCM: i.e. transition to a planned, proactive system of care. Nevertheless, there remains a great deal to be learned about the practicality, effectiveness, and cost implications of changing the organization and functioning of ambulatory care. However, empirical assessment depends on the independent collection of comparable data. While the discussion focused primarily on diabetes, the considerations are equally applicable to HIV.