Elderly person holding a cell phone

Making the Case for Chronic Care Management

You’re ready to start a CCM program. You know the positive impact it can have on the lives of your patients. But some people still aren’t convinced?

It likely won’t come as a surprise to find out that individuals living with chronic health conditions, on average, require more frequent and often more complex medical care than people who do not live with a chronic disease. The most common chronic diseases affecting the population often require consistent treatment and oversight by a provider or team. For patients relying on Medicare, this degree of continual care can result in sizable expenses for themselves as well their providers.

There are several ways to reduce the financial burden on Medicare-reliant patients living with chronic diseases. At the core, these cost-saving strategies stem from a population health methodology with the goals of improving preventive care and eliminating unnecessary expenses caused by common inefficiencies. These solutions for healthcare organizations and patients help to streamline care with a shared focus on accessibility, high quality of care, and cost savings.

The primary solution is improving access to care through virtual care management (VCM). These services and tools include remote monitoring, chronic care management, and behavioral health monitoring. Such tools and processes enable individuals with chronic conditions to get the care they need before their condition leads to a costly hospital stay or emergency room visit.


Report Cover


The Chronic Care Landscape

Below, we provide a comprehensive look at the nation’s most common chronic diseases — diabetes, hypertension (high blood pressure), chronic kidney disease, heart disease/failure, chronic obstructive pulmonary disease (COPD), and human immunodeficiency virus (HIV). These sections contain key information to contextualize the impact of each disease, with a focus on the financial implications placed on patients, providers/healthcare organizations, and payers.


According to the Centers for Disease Control and Prevention (CDC), an estimated 37.3 million people in the United States live with diabetes. Of these, approximately 14 million are Medicare recipients.

In the United States, Medicare is the largest payer for diabetic care, and hospitalizations related to diabetes account for a significant portion of Medicare spending. The Centers for Medicare & Medicaid Services (CMS) reports that 27.5% of Medicare fee-for-service (FFS) beneficiaries had a diagnosis of diabetes in 2019.

Hospitalization rates for individuals with diabetes have been rising in recent years, due in part to the growing prevalence of the disease. The number of Americans aged 65 and older with diabetes has nearly doubled over the past 20 years, as reported by the CDC. Patients with diabetes are also more likely to have other chronic conditions, such as heart disease, which can also lead to hospitalization.

In 2021, Medicare recognized the rising costs placed on hospitals for providing diabetic care. To motivate hospitals to provide a high level of care for diabetic patients despite the rising costs, the CMS offered an increased reimbursement. Hospitals that implement and offer a more comprehensive program for high-quality care are eligible for a greater level of reimbursement.

Enter virtual care management: A robust program for virtual care services can help providers and their diabetic patients better manage this condition and improve health outcomes. Such solutions are — and will continue — to help patients with diabetes better track their blood sugar levels, develop healthier eating habits and exercise routines, and stay on top of their medications. Virtual care management and remote monitoring tools are also providing medical teams with actionable data to build an informed care plan as well as identify and address potential risks before they reach the point of hospitalization.


Hypertension, or high blood pressure, is one of the most common chronic conditions among adults in the United States. In 2020, more than 670,000 deaths in the United States had hypertension as a primary or contributing cause.

In the U.S., it is estimated that one in three adults has hypertension. Among Medicare recipients, the prevalence of hypertension is even higher. Nearly half of all Medicare recipients have higher-than-normal blood pressure.

Hypertension, also known as “the silent killer,” is a major risk factor for heart disease and stroke, and it has a direct correlation to a large number of deaths per year. It can also lead to other chronic conditions, such as kidney disease and dementia. Hypertension requires regular, ongoing care and at-home management. For this reason, this can be one of the more costly chronic diseases for both patients and hospitals.

Chronic care management solutions can help reduce the costs associated with hypertension. Two of the most important resources to support patients living with this issue are remote monitoring and care coordination.

Remote monitoring allows physicians to stay abreast of their patients’ blood pressure levels and other important vital signs as well as provide timely interventions when needed. Coupled with tools for chronic care management, including care coordination, this helps ensure that patients receive the necessary care and services they need at the right time to help prevent an acute medical emergency. These tools have proven helpful in reducing hospital visits and readmissions and will continue to benefit patients into 2023 and beyond.

Chronic Kidney Disease

Chronic kidney disease (CKD) is another chronic condition frequently diagnosed among Medicare recipients. It has become a major public health concern in the United States, affecting an estimated 15% of the adult population. Similarly, approximately 14% of Medicare recipients are diagnosed with CKD.

The cost of treating patients with chronic kidney disease can be significant. It is estimated to be approximately $50 billion each year. As the disease progresses, it can lead to a costly increase in hospital readmissions. Additionally, CKD often leads to other complications, such as anemia, which can also add to the overall cost of care.

Chronic kidney disease is characterized by frequent episodes or emergencies that require hospitalization. These episodes can be caused by infections or a weakened immune system. It is very difficult to proactively manage and address this issue without close monitoring on a routine basis. This is a fundamental reason that virtual care can be so impactful for this disease and those affected by it.

Again, one way to help manage the cost of treating CKD is through chronic care management (CCM) — helping coordinate care between different providers, monitoring patient progress, and providing education and support to patients and their families. Virtual monitoring tools can also be used to track patient progress and help identify any potential problems early on.

Chronic Heart Disease

Heart disease is the leading cause of death for men and women in the United States. According to the Centers for Disease Control and Prevention (CDC), approximately 697,000 people die from heart disease in the United States every year. That’s one in every five deaths. Another statistic to grasp the severity and frequency of this issue is that one person dies from cardiovascular disease every 34 seconds.

There are substantial costs incurred by hospitals/health systems and patients to treat chronic heart disease and cardiovascular emergencies. The Centers for Medicare & Medicaid Services (CMS) published projections on the increase in healthcare expenditures moving forward. The cost of treating patients with chronic heart disease has been steadily rising. In 2011, Medicare and Medicaid spent a combined total of $108 billion on care for people with heart disease. This cost is expected to increase to $277 billion by 2030.

Heart failure is a common complication of chronic heart disease, and hospitalization rates for heart failure have also increased in recent years. Heart failure affects approximately 6 million Americans, with prevalence projected to increase by 46% and direct medical costs to reach $53 billion by 2030.

This is partly due to an aging population, as older adults are more likely to develop heart disease. It is also due to increases in obesity and diabetes, both of which are risk factors for chronic heart disease.

According to one report — Inpatient Utilization and Costs for Medicare Fee-for-Service Beneficiaries with Heart Failure — the Medicare allotment for the population with heart failure accounted for 34% of the total annual Medicare FFS population-allowed amounts. The report concludes that Medicare FFS beneficiaries with heart failure generate significantly higher costs due to high admission and readmission rates.

Chronic care management and virtual monitoring are two effective tools that can help improve the health of patients with chronic heart disease. These interventions can also help to reduce the costs associated with heart disease for both patients and payers alike, making the decision to use CCM resources worthwhile.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a chronic lung condition that affects millions of Americans. Medicare recipients make up a large majority of those hospitalized with COPD. As with most chronic conditions, there are significant costs associated with treating chronic obstructive pulmonary disease for both patients and healthcare organizations. With the rising costs of caring for this chronic disease, it can be unsustainable for many hospitals and healthcare payers.

In a comprehensive study and report by the U.S. Office of Health and Human Services, there are many insightful findings on trends among Medicare recipients and utilization of chronic care management resources from their care providers.

Medicare recipients with three or more chronic conditions who participated in a chronic care management program had a range of 17%-29% fewer hospitalizations than those who did not participate.

From the same study linked above, it was found that Medicare patients with COPD who received CCM had 38% fewer hospitalizations than those who did not receive chronic care management. This translated into estimated savings of $2,268 per patient over a 12-month period. Medicare patients with COPD had an average hospital stay of 6.5 days, and the Medicare costs for these patients were $9,700 per stay.

Human Immunodeficiency Virus

HIV is a very costly chronic illness to manage for both patients and healthcare organizations. In the United States, HIV care costs Medicare approximately $20 billion annually. Medicare covers a wide range of HIV-related services, including treatment and prevention.

The World Health Organization reported that in 2021, the number of individuals living with HIV reached 38.4 million people worldwide.

The number of HIV-related deaths in the U.S. have been declining, dating back to 2008. This is largely due to improvements in HIV care management and antiretroviral therapy. As with many illnesses during the height of the COVID-19 pandemic in 2020, fewer individuals were going in for HIV testing.

Chronic care management and a consistent adherence to a prescribed treatment plan and routine lab work are critical in treating HIV. This is fundamental to the improvements that have been observed in mortality rates for the disease decreasing.

With the addition of virtual care tools, providers can offer patients a more convenient way to check in regarding nonemergency health needs and coordinated care from a team of specialists. This helps develop a habit of regular communication between patient and provider, while also supplying the doctor with actionable data on their patients’ health status.

Data from the CDC shows that HIV disproportionately impacts minority communities, predominantly black/African-American and Hispanic/Latino. This is one of the biggest factors as to why virtual care management can be so impactful, as these underserved demographics have a statistically lessened access to care and utilization of care. Virtual care, or telehealth, can help alleviate many of the challenges to visiting a specialist, including taking time off from work, having no transportation, and lacking child care.

HIV treatment can be very costly. It has been estimated to cost patients more in a range of $300,00-$400,000 on average over the course of a lifetime. Virtual care can help to reduce these costs, which then reflect as reduced costs for Medicare to cover and, in turn, increased savings for practices or hospitals.

Improving Patient Outcomes With Virtual Care Management

The outlook for chronic care in 2023 is hopeful, especially as more and more medical communities adopt virtual care management. But a practice’s VCM is only as good as its partner. That’s where TimeDoc Health comes in.

At TimeDoc Health, we offer a chronic care management platform that supports your existing technologies by seamlessly integrating with your electronic health records system. We also offer care coordination services that engage your patients each month to ensure care plan compliance, remote monitoring adherence, and the proper utilization of care services. Our chronic care management solutions support your patients with broad coordination of care, extending beyond disease management. The TimeDoc Health CCM program streamlines holistic care, from medication management and appointment scheduling to durable medical equipment.

By implementing CCM, you can help patients better manage their chronic conditions, improve health outcomes, and enhance their overall quality of life without interrupting your current operations. CCM enables patients to easily track the many elements of their specialized care more easily while receiving ongoing support from a team of medical professionals.

Learn more about TimeDoc Health’s virtual care management solutions today. Request a demo to get started.