Disease Management Programs

Chronic diseases represent a major challenge for the U.S. healthcare system, accounting for nearly 90% of the nation’s $4.5 trillion in annual healthcare expenditures. Conditions like heart failure (HF), chronic obstructive pulmonary disease (COPD), and diabetes affect millions of Americans. For example, more than 6 million adults live with heart failure, 16 million have COPD, and 38 million are managing diabetes. As life expectancy increases, the prevalence and associated costs of these chronic conditions continue to rise, making effective, evidence-based interventions essential for improving patient health and reducing unnecessary hospitalizations.

Among these conditions, heart failure and COPD are leading causes of hospital readmissions in the U.S. One significant factor driving these readmissions is medication-related issues, especially polypharmacy. It is estimated that 21% of hospital readmissions are due to medication-related problems, with a median of 69% of these being preventable. Common issues include prescribing errors (such as underprescribing or incorrect dosages), inadequate monitoring, and non-adherence to treatment. Addressing these preventable medication-related problems can have a profound impact on reducing readmissions and improving patient outcomes.

An effective disease management program must also account for socioeconomic disparities and healthcare access, which are critical factors influencing patient health. It is estimated that 50% of all health outcomes can be attributed to social determinants of health (SDOH), while clinical care only impacts 20% of county-level variations in health outcomes. Successfully managing chronic diseases requires identifying and addressing SDOH that affect a patient’s ability to manage their condition, promoting health literacy to help patients better understand their disease, and developing a personalized care plan that addresses the individual’s needs rather than just the diagnosis.

At MindfulRx, we collaborate closely with our customers to design disease management programs tailored to the specific needs of their population. Through population-based initiatives and evidence-based recommendations targeting the most prevalent conditions among their membership, we help improve clinical outcomes and ensure long-term success in managing chronic diseases. Our goal is to enhance patient well-being, reduce hospital admissions and readmissions, and ultimately lower healthcare costs, while maintaining a high standard of care.

References:

  1. CDC report: Fast Facts: Health and Economic Costs of Chronic Conditions

  2. CMS. Guide for Reducing Disparities in readmissions.  Revised April 2024: https://www.cms.gov/about-cms/agency-information/omh/downloads/omh_readmissions_guide.pdf

  3. Hacker K. The Burden of Chronic Disease. Mayo Clin Proc Innov Qual Outcomes. 2024 Jan 20;8(1):112-119. Doi: 10.1016/j.mayocpiqo.2023.08.005. PMID: 38304166; PMCID: PMC10830426.