Closing the Gap: Improving chronic disease screening and care

Chronic disease is pervasive in the United States, afflicting six out of every ten adults according to the Centers for Disease Control and Prevention—with four in ten having two or more chronic diseases. Along with mental health conditions, it accounts for approximately $3.7 trillion in annual healthcare expenditures.

While there’s generally high awareness around the most prevalent chronic diseases such as heart disease, stroke, cancer, and diabetes, lesser known disorders such as Crohn’s disease and ulcerative colitis also have a significant impact on quality of life and require careful treatment plans. These two conditions are known as inflammatory bowel disease (IBD), which is diagnosed in more than 0.7% of Americans.

As we recognize Crohn’s and Colitis Awareness Week this December, let’s dive into measures that support quality care and strategies health plans should focus on to improve screening and care for members with these diseases in this final installment of Cotiviti’s Closing the Gap blog series.

The causes and health impacts of IBD

Unlike many other chronic diseases, the causes of Crohn’s disease, a chronic inflammation of the gastrointestinal tract, are still not well understood. Research indicates that genetic, hereditary, and environmental factors are significant in its development, with those who have a family member with the disease more at risk of developing it themselves. Factors such as diet and stress may aggravate the disease, but do not cause it. According to the Crohn’s & Colitis Foundation, it is most widely observed in those from 15 to 35 years old, and impacts men and women equally.

Ulcerative colitis specifically impacts the large intestine, causing ulcers in the lining of the colon. Similar to Crohn’s disease, its causes are still not widely understood, it can’t be prevented, and genetic factors are a significant risk. The Crohn’s & Colitis Foundation notes that most diagnoses of ulcerative colitis occur in patients in their mid-30s.

Common symptoms of both diseases include diarrhea, abdominal cramps, fatigue, and urgent bowel movements.

Treatment options for IBD

Medication is a common treatment for all forms of IBD, helping to suppress inflammation in the gastrointestinal tract and reduce symptoms. While they do not cure the underlying disease, changes to diet and nutrition can also help patients manage their symptoms.

However, surgery is often ultimately necessary for IBD patients over their lifespan—up to three-quarters of those with Crohn’s disease and one-third of those with ulcerative colitis. This can include removing a diseased bowel section for Crohn’s and a colectomy, or removal of the colon, for colitis patients.

Key quality measures for health plans

While there are no HEDIS^® or Star Ratings measures tied specifically to members with these diseases, improving scores across several specific measures can lead to more positive outcomes. For the HEDIS program, these include:

• Adults’ Access to Preventive/Ambulatory Health Services (AAP): Regular wellness visits are critical for those suffering from or at risk of developing IBD, enabling them to manage their conditions, be prescribed appropriate medication, and receive counseling on dietary and nutritional changes.
• Colorectal Cancer Screening (COL-E): Patients with IBD are more at risk of developing colorectal cancer than the general population, increasing the importance of regular screenings including colonoscopy and other options.

The most recently available HEDIS scores for the measures above show room for improvement, particularly for Medicaid plans. The lower scores for the AAP measure, as shown in Figure 1, may indicate that lower-income beneficiaries who may suffer from IBD may not be receiving optimal care. These scores may be influenced by factors such as growing provider burnout and long patient wait times to receive care. The ongoing Medicaid redetermination process, which has resulted in more than 10 million beneficiaries being disenrolled, may also contribute to deficiencies in care. 

Figure 1. Adults’ Access to Preventive/Ambulatory Health Services (AAP) HEDIS measure scores by line of business . Source: National Committee for Quality Assurance (NCQA).

In the Star Ratings program for Medicare Advantage plans, in addition to the Colorectal Cancer Screening measure, important measures for IBD patients include:

• Getting Needed Care: This measure, which is based on CAHPS^® survey responses, assesses how easy it is for plan members to receive care, including specialist care.
• Getting Appointments and Care Quickly: Also based on CAHPS surveys, this measure looks at how quickly the member was able to get care.

The national average for these measures also demonstrates room for improvement (Figure 2), as they have consistently remained below four stars for the past three years.

Figure 2. Medicare Advantage Star Ratings, 2022–2024. Source: Centers for Medicare & Medicaid Services (CMS).

Key strategies for health plans

As plans get ready to close out 2023, ensuring that members have timely access to quality care and are educated about the value of regular visits with a primary care physician (PCP) should be key priorities in their 2024 plans. Use multi-channel outreach including outbound calls, text messaging, and secure portal communications to advise members of the importance of annual wellness visits. PCPs can also refer patients with chronic conditions such as Crohn’s and ulcerative colitis to specialists and even community programs that help members prevent and manage their chronic conditions.

Medications for Crohn’s and colitis can help diagnosed members manage their symptoms, but can also suppress immune system activity. This makes it critical for care managers to help establish routine monitoring, recommend immunizations, and encourage members to stay on preventive care.

For Medicaid plans, diligence in ensuring minimal disruption to members following redetermination is vital, educating members about their coverage options and available community resources for those who lose eligibility.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).