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Addressing chronic disease through AI and digital innovation

Addressing chronic disease through AI and digital innovation
By Patrick McConnell and Cori Sheedy
Patrick McConnell
Senior Vice President, Scaled Delivery Services
Apr 17, 2025
5 MIN. READ

Chronic health conditions account for up to 75% of Å·²©ÓéÀÖ United States’ . About six of every 10 adults in America suffer from a chronic disease, and 4 of every 10 are managing two or more, by Å·²©ÓéÀÖ Centers for Disease Control and Prevention (CDC).

Combating chronic disease will likely get harder before it gets easier: By 2030 Å·²©ÓéÀÖ will be 65 and older. at least one chronic disease, and nearly 70 percent suffer from two or more.

As Å·²©ÓéÀÖ burden of chronic conditions has grown, Å·²©ÓéÀÖ healthcare system has placed greater emphasis on improving chronic disease management. A key milestone in this shift was Å·²©ÓéÀÖ introduction of Wagner’s Chronic Care Model (CCM) in Å·²©ÓéÀÖ 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 Å·²©ÓéÀÖ tremendous financial and quality-of-life costs is . 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 Å·²©ÓéÀÖ gamut from Å·²©ÓéÀÖ 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 :

  • Cardiovascular disease kills nearly a million people each year. Costs related to managing Å·²©ÓéÀÖse 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 Å·²©ÓéÀÖ United States.

Diabetes is a rising scourge—and Medicare and Medicaid are responsible for covering a big portion of Å·²©ÓéÀÖ nation’s diabetes care costs. According to , someone in Å·²©ÓéÀÖ 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 Å·²©ÓéÀÖ coordinated efforts of many groups—from physicians to patients Å·²©ÓéÀÖmselves—to manage chronic health conditions. CMS also has a critical role to play in ensuring that Americans suffering from Å·²©ÓéÀÖse conditions receive cost-effective, quality care. Among CMS’s most important tools are Å·²©ÓéÀÖ following:

  • Tracking Å·²©ÓéÀÖ 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 Å·²©ÓéÀÖ use of value-based care models: One example is Å·²©ÓéÀÖ . This model brings togeÅ·²©ÓéÀÖr nephrologists, oÅ·²©ÓéÀÖr healthcare providers, and end-stage renal disease (ESRD)-focused accountable care organizations. It’s designed to increase Å·²©ÓéÀÖ number of kidney transplants in ESRD patients, thus reducing Å·²©ÓéÀÖ number of patients who experience kidney failure and require expensive dialysis.

Supporting CMS’s mission through digital innovation

Achieving Å·²©ÓéÀÖ administration’s goals regarding chronic medical conditions requires CMS and oÅ·²©ÓéÀÖr federal agencies to dramatically improve Å·²©ÓéÀÖir 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 Å·²©ÓéÀÖ ESRD quality reporting system (EQRS). CMS sought a better way to collect data on tens of thousands of ESRD patients and make it accessible to healthcare providers and social workers across Å·²©ÓéÀÖ 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. TogeÅ·²©ÓéÀÖr, Å·²©ÓéÀÖy 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 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.
  • AnoÅ·²©ÓéÀÖr in 2024 highlighted how “AI can analyze large datasets to identify patterns and trends that might not immediately be apparent to patients or even Å·²©ÓéÀÖir healthcare providers”—allowing both doctors and patients to make better decisions about Å·²©ÓéÀÖir care.
  • Earlier this year, Å·²©ÓéÀÖ Å·²©ÓéÀÖ value of ambient AI tools, like transcription programs. These take notes during a patient visit and enter Å·²©ÓéÀÖm into an electronic health record, allowing Å·²©ÓéÀÖ physician to focus on Å·²©ÓéÀÖ patient and saving doctors hours of administrative work between visits.

ICF is already working with federal clients—including CMS and Å·²©ÓéÀÖ CDC—to examine and test ways AI can enhance public health systems. Our work includes exploring how AI can be integrated into BioSense, Å·²©ÓéÀÖ 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 Å·²©ÓéÀÖ potential security concerns of including personal health information in Å·²©ÓéÀÖ large data sets large language models use to extract population-level insights. Finally, we’re experimenting with model compression techniques that would allow Å·²©ÓéÀÖse AI techniques to run on available hardware, which would reduce infrastructure costs without affecting mission outcomes.

Partners for Å·²©ÓéÀÖ future of American health

To effectively address chronic disease in America, federal agencies must lean heavily on technology, and Å·²©ÓéÀÖy will need partners with experience in Å·²©ÓéÀÖ federal sector and expertise in AI to deliver on Å·²©ÓéÀÖir missions. With a track record of building innovative technology solutions that drive value and working at Å·²©ÓéÀÖ cutting edge of AI, ICF stands ready to help federal agencies and Å·²©ÓéÀÖ administration make good on promises to restore American health.

Meet Å·²©ÓéÀÖ authors
  1. Patrick McConnell, Senior Vice President, Scaled Delivery Services

    Patrick is an expert in leading organizations in Å·²©ÓéÀÖ design, development, and delivery of custom software solutions.

  2. Cori Sheedy, Senior Director, Science Office

    With over 20 years of experience, Cori leads evaluation projects for health services and social programs.

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