Chronic Disease

HEALTH REFORM: Dialysis Done Right

Medicare hasn't put the finishing touches on its new dialysis reimbursement policy quite yet (you have until December 16 to get your comments in) -- but has decided to invest in educating the public on various dialysis treatment options. It's part of a longer term effort to give patients more of a say in managing their chronic diseases, and in changing some of the inefficient ways Medicare pays for kidney care.

More than 350,000 Medicare patients with end stage renal disease undergo dialysis. Most patients undergo out-patient treatment three times per week at either an independent or hospital based facility -- in the United States, fewer than a tenth are treated at home. (Rita Rubin of USA Today notes that three treatments per week is the standard not necessarily because it is "optimal but because that's the way it has been done for nearly four decades.")


But Medicare's education campaign will help patients make more informed decisions about where and how often they are treated. 

HEALTH CARE: Of Carrot Cake and Oreos

Dr. David Kessler, as you've probably heard, is out with a terrific best-seller called "The End of Overeating: Taking Control of the Insatiable American Appetite."

The cover grabs your attention: very pure white glossy background with a carrot cake and carrots.

I don't like carrot cake. But as I told Dr. Kessler, if the cover picture were an Oreo, I wouldn't be able to have his book in my house.

I got to know Kessler while I was covering tobacco back in the late 1990s, but hadn't seen him in quite a few years until he spoke at a conference of health writers I attended last week.

He was the luncheon speaker: the healthiest of the box lunch options, the one I chose, was vegetables -- drenched in salad dressing -- on a white-bread roll, an apple, and two chocolate chip cookies in plastic wrap. I didn't want to eat them until Kessler began talking about how smells triggers cravings and my friend Ivan sitting next to me unwrapped his cookies. But, concentrating intently on the dress I wanted to wear at a college reunion this weekend, I ignored Ivan and the cookies, and listened to Kessler. Luckily, they weren't Oreos.

Anyhow, David happened to be heading to Washington this week, and we ended up having a longer and more provocative conversation about fat, policy, parenting, Oreos and social norms than either of us expected.

IN THE STATES: Doing Primary Care Right -- In Alaska (Part 2)

Yesterday we posted about innovations in primary care and quality improvement in a medical center that serves Alaska Native people. Today Dr. Doug Eby, a family physician and medical director of the nonprofit Southcentral Foundation nonprofit health system, talks about items on his care quality "to-do" list and what dimensions of health reform can help him achieve them.

Dr. Eby spends a lot of time thinking about end-of-life care -- specifically how to "improve the conversation." Many experts in the field of palliative medicine have found that better communication, earlier in the course of disease, can both improve care and save money. Those conversations give patients a clearer idea of the likely course of their disease, and physicians have a greater understanding of patients' values, choices, and wishes.

"We can do a much better job, at less cost," Eby said, adding his goal would be to "help people transition out of life in a wonderfully celebratory way," with their pain controlled, their wishes respected, their stories heard.

HEALTH REFORM: What Works (The Real Reality TV)

After The Speech -- and the Outburst -- and some of the usual political chatter, ABC‘s Nightline went inside the Mayo Clinic to show Americans what President Obama is talking about when he says we'll have "delivery system reform" and integrated care. It's one of at least three in-depth television pieces we've seen recently (more below on PBS and CBS) that illustrate how we can get high quality, patient-centered care at a lower cost.

Mayo is a household word. People know it's world-class care. What they may not know, and what Nightline showed, is that Mayo isn't excessively expensive. It isn't inaccessible to ordinary Americans. And it isn't built around the most esoteric and exotic and high tech specialist solutions. Yes they have them there, state of the art, best in class, and all that. But Mayo is built on primary care. On teamwork. On care coordination. On health information technology. On putting patients first.

QUALITY: House Calls Make a Comeback For Frail Elderly

In a standard office visit,  Dr. William Zafirau might not have discovered that "Mrs. S" had trouble handling the metered dose inhaler she needed for her chronic obstructive pulmonary disease.

On an old-fashioned house call, Dr. Zafirau had more time with his elderly patient. Time to talk. Time to observe. He learned that the arthritis in her hands made it hard for her to manipulate the inhaler.  He switched her to a nebulizer, and arranged pain relief and physical therapy for her arthritis. She's breathing better now despite her COPD. She is in less pain. She gets out more.

"You learn by being in a patient's home," Dr. Zafirau, a geriatrician at Summa Health System in Akron, OH,   explained in a telephone conversation this week. "You have a whole new level of honesty. There isn't the power differential that exists in the office. Plus it's a lot harder for patients to hide things from you. They want to be polite and not bother you. They don't lie, but it's not full disclosure."

IN THE STATES: Creating a Picture of Health(y) for the Nation's Capital

Washington DC is not the picture of health.

I'm not talking about political dysfunction. I'm talking about the health of the people who live here.

That may be changing.

The city has gotten lots of attention for its edgy school chancellor and education reform; it's also begun (with far less fanfare) a pioneering attempt to address health challenges in a city with a serious, and costly, burden of chronic disease.

Life expectancy in the nation's capital is eight years lower then the U.S. average. Mental illness, HIV/AIDS and cardiovascular disease rates are high. Lots of people are overweight; diabetes is a big problem, leading to a high rate of serious kidney disease and amputations. Costs are high (although the uninsured rate at under 11 percent -- 2007, pre-recession -- is lower than the national average of about 16 percent.)

QUALITY: When Medicaid Gets Health Right

We've written in the past about the North Carolina Medicaid Medical Home model, and its success in providing high quality care to vulnerable populations while saving money. The Kaiser Foundation's Drew Altman focuses on Community Care of North Carolina in his latest commentary. We aren't going to rehash the program here, (read our earlier posts or this Kaiser issue brief) but we were interested in what he identifies as the "few big messages to take away from this experience." The emphasis is ours:

QUALITY: More Likely to Get Sick, Less Likely to Have Access to Care

More evidence about the health care crisis facing poor people and minorities. Health and Human Services Secretary Kathleen Sebelius this week released a report, Health Disparities: A Case for Closing the Gap, examining widespread and worrisome disparities. Low-income Americans and racial and ethnic minorities experience higher rates of disease, face more barriers to accessing care, and often lack access to routine or preventative care.

Chronic disease is a particularly big problem. In general, minority populations are more likely than white populations to experience obesity, cancer, diabetes, or HIV. While about 39 percent of the general population suffers from chronic disease, the rate for African Americans is 48 percent. Seven out of 10 African Americans between the ages of 18 and 64 are overweight or obese. They are also more likely than other racial or ethnic groups develop cancer or be HIV infected.

HEALTH REFORM: A Call for Precision

A lot of new terms have entered the health care lexicon—but they don't always mean the same thing to everyone. We have a common vocabulary but not necessarily a common language. We asked Robert Berenson, MD, of the Urban Institute to guest blog on the need for precision.

It's encouraging that so much of the health care conversation in Washington is about delivery system reform, in particular the challenges posed by the intensive and expensive needs of people with multiple chronic diseases. It's also a little disconcerting. We're all talking, but are we talking about the same things?

We need more clarity, more precision.

How are we defining chronic conditions? I have a colleague who says it's like marriage—"It lasts a year or longer. It limits what you can do. It needs care."

Yes, it's funny. But it helps us think about what the definition should be. Under a liberal definition of chronic conditions, by last count I have at least four and fast approaching five, but I would say that I am in excellent health. Is having a certain number of chronic conditions what we're talking about? Or are we talking about those conditions that interfere with our ability to work, to function, to take care of  daily activities? Is it a disease that puts us on a trajectory that will lead to death? Is care management the same thing as care coordination?

COST: Industry Groups Outline Cost-Savings Initiatives

The industry groups that gathered at the White House last month and pledged to bring down health costs by $2 trillion in the next decade followed up with a 28-page document to the White House Monday. The letter addresses things like better management of chronic diseases, more administrative simplicity, appropriate utilization of medical services, quality improvement and medical error reduction, expansion of health information technology. In other words, the industry gave a real world vote of approval to what a lot of what academic researchers and health policy experts have been saying about the ways to bring down the costs and improve care.

However, the document (from the American  Medical Association, PhRMA, the American Hospital Association, the SIEU, America's Health Insurance Plans, and AdvaMed, which is the main medical device trade group) was a vague on whether there were any teeth in the pledges to do this, that and the other thing, or on what would happen if these initiatives fall short (or fall apart).