Addressing chronic disease through AI and digital innovation

Chronic health conditions account for up to 75% of the United States’ $4.5 trillion in annual health care spending. About six of every 10 adults in America suffer from a chronic disease, and 4 of every 10 are managing two or more, according to recent estimates by the Centers for Disease Control and Prevention (CDC).

Combating chronic disease will likely get harder before it gets easier: By 2030 the entire baby boomer generation will be 65 and older. Eighty percent of Americans in this age group have at least one chronic disease, and nearly 70 percent suffer from two or more.

As the burden of chronic conditions has grown, the healthcare system has placed greater emphasis on improving chronic disease management. A key milestone in this shift was the introduction of Wagner’s Chronic Care Model (CCM) in the late 1990s. This widely adopted framework outlines essential elements for effective chronic disease care, emphasizing proactive, coordinated treatment through patient self-management support, evidence-based decision-making, and strong community and health system partnerships. CCM has influenced modern approaches to chronic care delivery, including value-based care models that prioritize prevention and long-term patient outcomes.

Addressing the tremendous financial and quality-of-life costs is a major focus of the second Trump Administration. Innovative technology and policy changes will be essential to achieving that goal.

The catastrophic toll of chronic disease

In 2015, Medicare began reimbursing for chronic care management services for patients with multiple, or comorbid, chronic conditions. The Centers for Medicare & Medicaid Services (CMS) tracks health outcome measures for disease prevalence, costs, and hospitalizations for 60 specific chronic conditions. Tracked measures run the gamut from the brain (Alzheimer’s disease and dementia) to cardiovascular (heart failure, hypertension, and ischemic heart disease) to mental health (depression and schizophrenia).

Chronic health conditions take a tremendous toll on American healthcare spending, quality of life, and productivity. According to the CDC:

• Cardiovascular disease kills nearly a million people each year. Costs related to managing these conditions are predicted to exceed $2 trillion annually by 2050.
• About 1.7 million people receive a cancer diagnosis each year. Cancers account for about 600,000 annual deaths.
• Chronic kidney disease (CKD) affects approximately 14% of adults in the United States.

Diabetes is a rising scourge—and Medicare and Medicaid are responsible for covering a big portion of the nation’s diabetes care costs. According to a 2023 article in Diabetes Care, someone in the United States is diagnosed with diabetes every 20 seconds. In 2017, direct costs associated with diabetes ran to $237 billion, with Medicare and Medicaid paying two-thirds of that total.

CMS’s role in managing chronic disease

It takes the coordinated efforts of many groups—from physicians to patients themselves—to manage chronic health conditions. CMS also has a critical role to play in ensuring that Americans suffering from these conditions receive cost-effective, quality care. Among CMS’s most important tools are the following:

• Tracking the effectiveness of care: The agency uses several sources to assess healthcare providers, promote care coordination, and incentivize better patient outcomes. CMS recently shifted its clinical quality measurement from a manually intensive and claims-based process to electronic quality measures (eCQMs). This digital modernization produces more accurate and reliable assessments of providers and hospital organizations.
• Developing and promoting the use of value-based care models: One example is the Kidney Care Choices Model. This model brings together nephrologists, other healthcare providers, and end-stage renal disease (ESRD)-focused accountable care organizations. It’s designed to increase the number of kidney transplants in ERSD patients, thus reducing the number of patients who experience kidney failure and require expensive dialysis.

Supporting CMS’s mission through digital innovation

Achieving the administration’s goals regarding chronic medical conditions requires CMS and other federal agencies to dramatically improve their technological capabilities. ICF has partnered with CMS in recent years to begin this work, deploying our experience and expertise to build tech-driven solutions that are cost-effective, interoperable, and quick to market.

One recent collaboration involved modernizing the ESRD quality reporting system (EQRS). CMS sought a better way to collect data on tens of thousands of ERSD patients and make it accessible to healthcare providers and social workers across the country with a goal to improve patient care and reduce costs.

Through a scaled-agile approach, ICF engineers worked closely with CMS stakeholders and subject-matter experts. Together, they developed a modern system that now gives more than 200 transplant centers access to transplant waitlists and relevant transplant preparation information. This human-centered collaboration allowed ICF and CMS to modernize EQRS with end users and mission outcomes in mind, while also ensuring taxpayer dollars were spent responsibly.

AI and chronic disease management

Opinions and predictions abound about AI’s potential to revolutionize chronic disease management:

• The authors of a 2023 article in Cureus argued that AI could become one of doctors’ primary tools in diagnosing diseases, keeping tabs on patients, and predicting treatment outcomes for patients with chronic diseases.
• Another article published by Health Data Management in 2024 highlighted how “AI can analyze large datasets to identify patterns and trends that might not immediately be apparent to patients or even their healthcare providers”—allowing both doctors and patients to make better decisions about their care.
• Earlier this year, the National Rural Health Association highlighted the value of ambient AI tools, like transcription programs. These take notes during a patient visit and enter them into an electronic health record, allowing the physician to focus on the patient and saving doctors hours of administrative work between visits.

ICF is already working with federal clients—including CMS and the CDC—to examine and test ways AI can enhance public health systems. Our work includes exploring how AI can be integrated into BioSense, the CDC’s cloud-based digital platform that helps local, state, and national officials monitor and respond to health threats like disease and addiction. We’re also working to address the potential security concerns of including personal health information in the large data sets large language models use to extract population-level insights. Finally, we’re experimenting with model compression techniques that would allow these AI techniques to run on available hardware, which would reduce infrastructure costs without affecting mission outcomes.

Partners for the future of American health

To effectively address chronic disease in America, federal agencies must lean heavily on technology, and they will need partners with experience in the federal sector and expertise in AI to deliver on their missions. With a track record of building innovative technology solutions that drive value and working at the cutting edge of AI, ICF stands ready to help federal agencies and the administration make good on promises to restore American health.