Chronic Disease

For the cynics out there who don't believe you can cut costs while improving care: here's more evidence that you're wrong. A Chicago-area pilot project lowered costs of care for diabetics—while improving their health.

First, the program saved money by taking the counterintuitive step of lowering or eliminating co-pays for diabetes patients. Though that increased upfront costs, it ensured that diabetics didn't skimp on needed care, which helped keep them out of the hospital and the E.R.

Second, the pilot borrowed the concept of the medical home. Instead of using a physician or nurse practitioner to coordinate care and work with the patient, the pilot used pharmacists. The pharmacists were trained to give diabetics advice not only on medication, but on exercise, lifestyle, and weight management. Not a traditional role for pharmacists, but it worked. Patients trusted pharmacists and took their advice.

Republican music to our ears: "Will health reform require an upfront investment? Yes. But will that investment pay off in the long-term? Yes it will."

That's former HHS Secretary Tommy Thompson, who served under President  George W. Bush, writing in the Politico, arguing for comprehensive reform. He didn't spell out precisely how he defines comprehensive reform, and he didn't explicitly endorse any of the main Democratic approaches, but he sure extended a warm fiscal handshake, a welcome note of bipartisanship as Congress grapples with how to finance expansion of coverage and an overhaul of the system.

Thompson wrote that sustainable, affordable health care reform is an important investment in the future, but Congress must heed the estimates of the Congressional Budget Office. In the past, when CBO calculated the cost of health care reform, he said, it didn't adequately assess the savings that will come from changing the health care system to provide more value and promote wellness in the long run. Thompson writes:

Teenagers. They grow up fast—pretty soon they're starting to drive, applying for college, and, according to a recent study, not getting the preventative care they need. And if we're serious about a health care system that promotes wellness, prevention and a long-term effort to bring down rising rates of chronic disease, the teen years are a good place to start.(Not to mention that it might help their parents' blood pressure.)

Using data from the Medical Expenditure Survey, researchers at the University of California, San Francisco determined that only 38 percent of adolescents age 10 to 17 had a preventative health care visit in the past year. UCSF researchers also found that most teens weren't getting counseled on important health issues such as dental care, healthy diet, regular exercise, wearing a seat belt or bicycle helmet, and the dangers of secondhand smoke. Only 10 percent of teens discussed all of these issues with their doctor, and less than half discussed any of these issues with their doctor.

Listen to anyone caring for an elderly, frail, or chronically ill family member, and you'll hear a litany of worries. They'll tell you about medical specialists who don't coordinate with one another. Patients who are sent home from the hospital or rehab without adequate information about follow up care and complex medication regimes. Delays in getting patients the care they need when they need it. In short, a fragmented, disconnected system that seems unaware that it's supposed to be all about the patient.

"You're on your own," said Carol Levine, director of the families and health care project at the United Hospital Fund, who cared for her own husband for 17 years after a car accident made him a quadriplegic. "The system has gotten worse. It's more complex. There are more transitions."

What can health care reform do to address these problems? Done right, health care reform can achieve an awful lot, according to participants in a recent AARP Solutions Forum on Capitol Hill, one of a torrent of events in Washington recently about the daunting problems of family caregiving and coordinating or managing patients with multiple chronic conditions. (My colleague Paul Testa will post soon about an Alliance for Health Reform event on care coordination).

The outlook is bleak for people suffering from chronic disease, according to a recently-released survey. More and more people suffer from chronic illnesses, and they are not getting the care they need. And it's not getting any better in a recession.

About three-fourths of our nation's health care spending is on chronic diseases. Learning how to better manage chronic diseases lilke diabetes and congestive heart is a work in progress; we should learn from both the programs that are working as well as those that are not. One goal of health reform is to develop a health care system that is less fragmented, more able to provide the coordinated care needed to control chronic diseases. That will mean changing how we deliver health care, and how we pay health care providers.

Blood, sweat, and billions have gone toward studying whether different care delivery models can improve health outcomes of the chronically ill while holding down costs. A recent set of Medicare disease management pilot programs with these twin goals showed, at best, uneven results. As previously noted in this space, only three, including a promising one in Pennsylvania, have been extended beyond their initial periods. Even these programs did no yet reduce overall costs of care for the chronically ill. The key word in that last sentence is "yet."

We must not be fickle in funding delivery system innovation. Politicians and the general public have microscopic attention spans and wildly unrealistic expectations as to how quickly new health care programs can fulfill their promise. This is particularly problematic for innovations that deal with the management of chronic diseases. The problem is compounded when patients are poor, uninsured or underinsured and suffer from illnesses that were undertreated if they were treated at all. As detailed below, the state of California is discovering this at the outset of a major public investment in pilot programs focused on these populations.

Beyond questions of effective long-term stewardship of scarce public resources, there are real human costs to short-lived serial infatuation with new pilot programs. We nearly all believe that a real and ongoing relationship between patient and provider is paramount to quality medical care, yet we often reshuffle which federal program people qualify for and what care facilities they can access. Ideally patients should have some stability and consistency of access points, particularly within a system that can seem byzantine and impenetrable even to those who study health policy for a living.

Holy Cross Hospital, just outside Washington, has created a special emergency room section for older patients, complete with staff trained in geriatrics and communication, wooden handrails for safe walking, comfy chairs for family members, and extra thick ER mattresses designed to protect the fragile skin of the elderly against fast-developing bedsores.

Hospital CEO Kevin Sexton got the idea after, what else, a stressed out phone call from his elderly mom in a New Jersey emergency room. "It was the combination of her being there quite some time and it being very crowded and chaotic. It came to me we really do treat seniors poorly in that setting," he told the Washington Post. Developed with the assistance of outside experts on aging, there is apparently only one similar program in the country.

Elderly patients with traumatic injuries or acute crises (i.e. car crashes or heart attacks) will go into the regular ER, but most elderly patients seek emergency treatment because of pain, falls, or problems related to chronic conditions. They will be steered to the special seniors section.

The article focused on stress reduction and comforts, but the care model also has implications for better outcomes, even beyond those extra precautions about falls and bed sores (which can be very dangerous).

We wrote the other day about the failures and limitations of Medicare's disease management experiments. Les Masterson at Health Leaders Media writes that we need to know a lot more about where the Medicare Health Support projects in particular fell short, what aspects might have worked, and how to build better disease management for the future. He interviewed two Health Dialog (no relation to this blog) disease management company officials about the takeaway lessons. They listed three:

1. Target the right people for interventions and support those patients with the appropriate services
2. Get timely information so you can reach at-risk and recently discharged patients as soon as possible
3. Providers [not just outside disease managers] are an important part of the healthcare team

For Masterson's fuller discussion, click here. (The part I found most relevant was at the end of his article)

A few days ago, we wrote about hype and hopes in health care reform, the constant search for the magic low-cost, high-quality elixir. Soon after, we found ourselves reading several articles and blog posts and attending a panel discussion sponsored by Health Affairs making us wonder whether disease management is the latest example of the hype-hope cycle.

After thinking about it, and reading about it for a few more days (the Health Affairs Jan/Feb 2009 issue focuses on chronic disease), our conclusion is—only sort of. A lot of what's been tried so far hasn't worked—-if you are focusing on disease management within the Medicare fee-for-service context. Luckily that's not the only context. The building interest in gainsharing, payment bundling, integrated delivery systems, medical homes etc. all include some form of managing and coordinating care of chronic disease. The concept still makes sense. Chronic disease is not going away or getting any cheaper. So it needs to be managed. And we are still learning how to do that.

Kaiser Permanente, the Mayo Clinic and Intermountain Health Care, three health systems known for their emphasis on primary care, care coordination and integrated delivery systems, have collaborated on a five-year vision for improving how we deliver health care. The paper outlines practical steps that would move us from a fragmented, inefficient, and expensive system to one based on teamwork, care coordination and sound medical evidence to guide clinical decision-making. The five-year plan is built around an expanded health information technology infrastructure and an ambitious set of pilot programs, drawing in Medicare, other public programs and private insurers, that would lead us to a system where we pay for good value, and good quality. Hallmarks would include: