As Americans age, they’re increasingly dealing with multiple chronic conditions like diabetes. The best treatment plan sees the big picture.
Almost 40 million Americans have diabetes — and as a result are at risk of developing a long list of other chronic conditions. That’s straining the traditional healthcare system in this country.
Mike Uchrin
CEO and Co-Founder, Monogram Health
“As adults are living longer, they’re dealing with more and more chronic conditions,” noted Mike Uchrin, CEO and co-founder of Monogram Health, a provider of in-home, multi-specialty treatment and benefit management services. “But that’s not really how the U.S. healthcare system was originally set up — it’s set up for specialists and sub-specialists focusing on a single organ.”
Specialist fatigue
For patients — especially seniors — dealing with multiple chronic conditions, this can lead to what Uchrin terms “specialist fatigue.” “Our average patient has upwards of eight chronic conditions,” Uchrin noted. “They’re seeing seven specialists. They’re taking 12 prescriptions, and those 12 prescriptions were prescribed by about four and a half physicians. Their entire lives are about going to multiple physicians.”
This is especially true for patients living in rural areas, where social determinants of health define crucial barriers to healthcare, including a lack of specialists, transportation, food security, and internet access.
Taking care to patients
Part of the solution is to shift the overall approach. “We’re treating those patients where they’re most comfortable,” Uchrin explained. “In their own home.”
Shaminder Gupta, M.D.
Chief Medical Officer, Monogram Health
Shaminder Gupta, M.D., CMO of Monogram Health and a practicing internist and nephrologist, calls this “taking care to them”’ — “Our model deploys nurse practitioners, physicians, pharmacists, social workers, and others. They approach the patient holistically to address those primary illnesses and help prevent further progression, while also addressing the acute flare-ups of those chronic conditions.”
Gupta notes that this holistic approach results in a much better patient experience. Two crucial aspects of this are the fact that patients and their caregivers have 24/7 access to Monogram, and the inclusion of social workers as part of these care teams.
“In traditional medicine,” Gupta noted, “the social workers are an ‘add-on’ — if the doctor identifies a problem, they outsource that to a social worker that the patient has to find. We’re already solving for this by going into the home and seeing with our own eyes what the hurdles are, and the social worker can lead that interaction.”
Better outcomes, lower costs
Combined with a fully digitized system that ensures uniform, standardized, and optimized treatment, this approach leads to better outcomes, better adherence to medications and therapies — and lower costs. “We’re able to bring down hospitalizations by 20%,” Uchrin noted. “We’re able to bring down the overall total cost of care by about 30% for each enrolled patient, and by 8% to 10% on a population basis. We really move the needle.”
Monogram Health is already serving more than 200,000 patients across 36 states, in both urban and rural markets — the latter is critical in today’s healthcare landscape as quality care becomes harder to access in remote locations.
As a value-based company, Monogram Health partners with the leading health plans and providers to offer this benefit through the patient’s existing health plan coverage, at no additional cost to the patient. By reducing the number of ER visits and hospitalizations, as well as copays and out of pocket expenses, Monogram Health is lowering the cost of care for health plans, providers, and patients alike.
In general, Monogram is making a difference in people’s lives. “We believe that healthcare is about people taking care of people,” Uchrin said. “We look to become an extension of our patients’ families.”
To learn more, visit monogramhealth.com
