How Chronic Diseases Fit into Value Based Care (VBC)
Mrs. Thompson, age 72, has diabetes, hypertension, and early-stage kidney disease. She sees her primary care physician every few months, but most of her life — and most of her health challenges — happen outside the clinic walls. Without regular follow-up, her blood sugar drifts upward, her blood pressure spikes, and the risk of hospitalization looms. In the traditional fee-for-service model, her physician is paid only for the office visit. In Value Based Care (VBC), the goal — and the payment model — changes: success is measured by her outcomes, not just encounters.
Chronic diseases like hers are at the very heart of VBC. They are prevalent, costly, and often manageable with consistent, proactive care. Understanding how they fit into VBC — and specifically how they align with programs like Chronic Care Management (CCM) — is essential for any practice transitioning to a value-focused model.
Why Health Providers Should Embrace Value Based Care
For providers, VBC isn’t simply a new reimbursement model — it’s a chance to redesign care in a way that’s financially sustainable, operationally smoother, and more satisfying for both patients and clinicians.
Economic benefits
Traditional fee-for-service rewards volume, not value. Many critical activities — phone calls, medication adjustments, patient coaching — go unpaid. VBC unlocks new revenue streams through CCM, Remote Patient Monitoring (RPM), Transitional Care Management (TCM), and ACO shared savings. Practices that excel at these services can reduce avoidable hospitalizations, meet quality targets, and earn performance bonuses. In 2023, the Medicare Shared Savings Program alone generated $2.1 billion in net savings nationally, proof that preventive, coordinated care delivers financial as well as clinical returns [5][6].
Operational efficiencies
VBC promotes workflow redesign. By delegating appropriate tasks to clinical staff, structuring routine outreach, and integrating technology-enabled monitoring, practices can replace reactive “firefighting” with proactive management. This translates into fewer urgent calls, more predictable schedules, and a team that spends more time on planned interventions and less on damage control.
Impact on health outcomes
Consistent follow-up, early intervention, and patient engagement lead to measurable improvements in blood pressure, blood sugar, symptom control, and medication adherence. These gains not only improve quality metrics but also create a feedback loop where better outcomes drive stronger reimbursement and greater patient loyalty.
Defining Chronic Disease
A chronic disease is a condition lasting one year or more that requires ongoing medical attention and/or limits activities of daily living [1]. Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States — and leading drivers of the nation’s $4.9 trillion annual health care costs.
The Resource Burden of Chronic Disease
Chronic diseases consume a disproportionate share of health care resources, driving the majority of hospital admissions, specialist visits, diagnostic testing, and prescription use. A relatively small percentage of high-need patients can account for most of a practice’s workload and costs. These cases often require frequent follow-up, complex medication management, and ongoing care coordination, much of which happens outside billable office visits.
How Value Based Care Eases the Resource Strain
Programs like CCM, RPM, TCM, and Behavioral Health Integration (BHI) are designed to move much of this work outside the four walls of the clinic. By focusing on prevention, early intervention, and sustained engagement, they can reduce avoidable acute care episodes and free in-office time for patients who truly need it.
Example:
A CCM program can address a medication adherence issue within days rather than waiting for the next quarterly appointment. An RPM system can detect early signs of fluid retention in a heart failure patient and prompt a medication adjustment before hospitalization becomes necessary.
Chronic Disease in the Context of Value Based Care
Value Based Care models — such as the Medicare Shared Savings Program (MSSP), Primary Care First, and various Accountable Care Organization (ACO) frameworks — are built to improve quality while controlling costs. Chronic diseases fit perfectly into these models because they:
- Drive utilization: Chronic conditions generate frequent visits, tests, and admissions.
- Are measurable: Outcomes like HbA1c, blood pressure, and readmission rates can be tracked and tied to incentives.
- Are modifiable: Proactive management can reduce complications and lower costs.
- Concentrate resource use: Managing these patients effectively has an outsized impact on practice performance.
Chronic Care Management (CCM) and Chronic Diseases
Chronic Care Management is a Medicare-covered service for patients with two or more chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation, or functional decline [2].
- Requires documented consent and a comprehensive, shareable care plan.
- Involves at least 20 minutes per calendar month of non-face-to-face clinical staff time under a physician’s or other qualified professional’s direction.
- Includes variants for complex CCM and for time personally spent by the billing practitioner.
CCM aligns perfectly with value-based goals: it reduces preventable acute care, improves patient engagement, and generates metrics that support quality reporting — while creating a reimbursable framework for the non-visit work chronic disease demands. Lara Health’s CCM platform captures all required documentation, tracks time automatically, and alerts teams to gaps before they affect compliance or reimbursement.
Other Value Based Care Programs Addressing Chronic Disease
Transitional Care Management (TCM): Bridges the vulnerable 30 days post-discharge to prevent readmissions.
Remote Patient Monitoring (RPM): Allows daily collection and review of vital signs for acute or chronic conditions.
Behavioral Health Integration (BHI): Brings mental health care into the chronic disease workflow.
Principal Care Management (PCM): Focused monthly coordination for a single serious chronic condition.
Conclusions
Chronic diseases consume much of the healthcare system’s time, money, and energy — but they also represent the greatest opportunity for transformation. By adopting Value Based Care strategies like CCM, RPM, and TCM, providers can improve outcomes, lower avoidable utilization, and run a more efficient, financially resilient practice.
Ready to turn chronic disease management into a driver of VBC success? Learn more about chronic care management with Lara Health and see how integrated tools streamline documentation, improve engagement, and keep patients healthier, longer.
FAQs
What counts as a chronic disease for CCM?
Any condition lasting at least 12 months (or until death) that poses significant health risk, such as diabetes, heart disease, or COPD [2].
Why are chronic diseases so resource-intensive?
They require frequent monitoring, multiple medications, and ongoing coordination — often representing most of a provider’s workload [1].
How does CCM reduce provider resource strain?
By shifting much of the work to proactive, coordinated follow-up outside in-office visits, backed by monthly reimbursement [2].
Do all VBC programs require multiple chronic conditions?
No. CCM requires two or more conditions; PCM focuses on a single serious condition; RPM may apply to acute or chronic conditions [2][4].
How do ACOs link to chronic disease management?
ACOs aim to improve quality and reduce cost through coordinated care — the MSSP generated $2.1 billion in net savings in 2023 by doing just that [5][6].
References
CDC — About Chronic Diseases. 2024
CMS — Chronic Care Management Services (MLN909188). June 2025
CMS — Transitional Care Management Services (MLN908628). July 2025
HHS/CMS — Billing for Remote Patient Monitoring (Jan 2025); CMS — Telehealth & RPM (MLN901705). April 2025
CMS — Press Release: MSSP net savings (2023). Oct 29, 2024
CMS — Medicare Shared Savings Program ACO overview page. 2025
