Chronic Disease

HEALTH REFORM: Dialysis Done Right

Allison Levy — Mon, 23 Nov 2009 21:30:00 -0500

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.

"These education sessions will provide patients with chronic kidney disease information they need to understand their treatment options and participate in better management of their own care," Dr. James Sloand, senior medical direct of Baxter's North American renal business, told the Chicago Tribune recently. "This program empowers individuals to take measures to slow the progression of their kidney failure."

One option, as Bruce Japsen explained in that Tribune story, is for more patients to get dialysis at home. It's less expensive -- and research suggests that it is more effective as patients can "dialyze" more frequently, for longer periods of time and on their own schedule.

As Japsen explains, reimbursement for dialysis is complicated by Medicare's current payment structure, a "prospective payment system known as the basic case-mix adjusted composite payment system." In case you need a translation -- dialysis outpatient facilities bill Medicare for the routine dialysis service separately from some injectable medications and non-routine laboratory tests. These separately billable items account for 40 percent of total Medicare payment per dialysis treatment -- and are billed on a fee-for-service basis.

But, in September, the Centers for Medicare and Medicaid Services released a proposed rule to change that. Beginning January 1 of 2011, Medicare will "bundle" all the routine dialysis outpatient care -- the dialysis itself, the drugs and those lab tests -- into a single base payment (around $200 but adjusted for location and patient characteristics). (Look at this presentation for more specific details.)

Since 1972, the government has financed dialysis treatment regardless of the ESRD patient's age -- it cost an annual $10,000 per dialysis patient then, and more than $73,000 now. But Medicare believes that by bundling the payment, unnecessary medications will be eliminated and patients will receive efficient, quality and patient-centered care.

"Combining a fully bundled prospective payment system with required performance standards would encourage facilities to operate more efficiently and ensure that beneficiaries receive high quality care, while saving dollars for both beneficiaries and the Medicare program," said Jonathan Blum, director of the agency's Center for Medicare Management. (Here is another recent post about another form of bundled payment.) Not only will patients receive efficient and high quality care -- but they will be able to make an informed choice concerning the treatment option that works best for them.

HEALTH CARE: Of Carrot Cake and Oreos

Joanne Kenen — Fri, 23 Oct 2009 17:19:00 -0400

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. (I took him to a place where only the tea was supersized.)

Normally I avoid writing about books until I've finished reading them (which is why we have only given a passing shout-out to T.R. Reid's excellent The Healing of America... I will tell you just how excellent it is when I get past page 50... which will probably be after this weekend's college reunion). But while I'm only about halfway through Kessler's book, I wanted to share some of our conversation while it is still fresh in my mind.

"The End of Overeating" is not about health reform or health insurance, or even about how health reform will improve the care and management of obesity-related diseases like diabetes and heart disease (although that will help). Nor is it just about the social determinants of health or steps like kids getting more exercise at school and healthy school lunches and walkable neighborhoods and all that. The book isn't about government regulation (although better and more useful labeling, he told me, is essential -- and the Froot Loops "Smart Choices" flap may help lead to better public awareness.)

His book is about our bellies. And our brains.

About how and why our brains tell us to keep putting large quantities of bad food in our bellies. And how we become wired to want more and more of the bad food that gives us a quick fix and still leaves us wanting more. Why I can't have Oreos in my house, and why the top layer of my wedding cake in my mom's freezer "talked" to her so loudly and insistently that she gave it away while I was on my honeymoon. And how and why the social norms in contemporary America have changed. We used to eat food. Now we eat processed stuff. Stuff engineered by food companies that know exactly what they are doing. A dash of fiber and a bit of fortification buried under layers and layers of sugar, salt and fat.

And it's everywhere. And we eat it all the time. And it's getting worse and worse.

Kessler writes:

Foods built layer upon layer to stimulate our senses. Foods high in sugar, fat and salt, and the cues that signal them, promote more of everything: more arousal... more thoughts of food... more urge to pursue food... more dopamine-stimulated approach behavior... more consumption... more opioid-driven reward... more overeating to feel better... more delay in feeling full... more loss of control... more preoccupation with food... more habit-driven behavior... and ultimately, more and more weight gain.

We don't just have palatable food. We have hyper-palatable food. We don't have habits, we have conditioned hyper-eating, driven behavior. Conditioned driven behavior isn't exactly the same thing as an addiction to a drug or nicotine... but it's a close cousin.

The result, in his view, is an obesity epidemic so severe that it has emerged as the biggest public health challenge of our lifetimes. This comes from a former FDA commissioner who did about as much as anyone on earth to combat tobacco. And who has also been involved in the fight against HIV/AIDS.

We're already spending $147 billion a year on obesity -- twice what we spent a decade ago. And it's only getting worse. Reversing the obesity epidemic, he told me, is also "harder than anything we've ever done in public health."

I look around and see what he means. Too much. All the time. Everywhere.

Today, at a college snackbar, I saw "macaroni and cheese pizza." (It's just what it sounds like.) Yesterday morning, as I wrote part of this post in an airport departure lounge, I saw a coffee stand at each end of the corridor, but they weren't serving what we used to think of as "coffee." This coffee is loaded with syrups and flavors and chocolates and garnishes and whipped cream. There was a diner at one end of the corridor, (fries, fries fries) and a dubiously greasy-smelling seafood place offering breakfast at another (I didn't dare look). In between, there was no shop for me to pick up a cheap watch to replace the one I dropped rushing out of the house for my plane. But there's a pizza place, an Arby's, a California Tortilla, McDonalds (with really really long lines), a Chinese take-out place, a Quiznos, and yes a place for me to buy a newspaper and a bottle of water -- but the woman in front of me in line was getting a Coke and a candy bar for breakfast. And the bigger-than-it-used-to-be bag of M&Ms on the newsstand counter had a logo about fighting breast cancer.

So a lot of what David Kessler and I spent an afternoon talking about wasn't so much about the Baucus bill or the Waxman bill, or medical homes or more nurses. It was about social norms, and how to change them. He has some ideas in the book, but much of that is still a conversation going on in his head. We changed the social norms for smoking, even before the laws he fought for were enacted. And we're going to have to change the social norms for food. Kids used to say, "Daddy please don't smoke," Kessler recalled. How do we get them to say, "Daddy, please don't buy me fast food." Because without significant changes in what we eat, how we eat, when we eat, and why we eat, the costs -- both economic and physical -- to ourselves and our nation will be overwhelming. Way bigger than any Oreo.

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

Joanne Kenen — Fri, 18 Sep 2009 14:27:00 -0400

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.

Second, he and his colleagues want to address the "high utilizers," the people who are coming in 15 or more times a year. "How do we learn more about them? How do we better meet their needs?"

"We need to understand the social complexity of their lives much better," Eby said. That will require more than managing physical symptoms. They will also have to examine homelessness, social supports, and mental health. "We need to bring in behavioralists to understand their story," and find ways of addressing their needs in the community.

Third, they want to build on the healthy habits of pregnant women to create a continuum of childhood health from preconception through the first few years of life.

"We know that a large number of pregnant women, and their families, will make very positive lifestyle changes. They'll stop smoking and drinking, they'll get enough sleep, they make a bunch of healthy changes. We've convinced people as a society that that's important to do, and they are a lot healthier. Then, on day one after their pregnancy -- it's over. That's a lost opportunity -- for the mother and the child." Some lifelong patterns, including eating habits and other factors contributing to obesity "are pretty much in place by the time you start school."

Eby's team is exploring how to change patterns of care to create more continuity, instead of repeated broken relationships. For instance a woman may switch from primary care to obstetrics or a midwife, back to primary care, while the child goes off to a pediatrician. "We engineer three or four or five breaks by design" instead of leveraging that magic moment of a baby's birth into a health opportunity for the child, parents, "aunts, uncles and grandparents."

Speaking by telephone recently from Anchorage, Eby sounded ready for health reform -- if it gives him the tools he needs to improve care not only of individuals but of a complex community. "The U.S. health care structure is the dumbest thing created by human beings in the history of mankind," he said. "There are good things in it, of course, but the system is insane."

What he's looking for -- besides of course, help for the uninsured -- is change in the underlying way the system works.

He wants to be paid for "doing the right stuff" for improving the health of the population over the long term. He wants to be rewarded for good outcomes, now and over time. He wants a system that will reimburse him for things he knows work -- like care coordination, complex case management, and a robust medical home -- that aren't highly valued, if they are valued at all, in the current payment system.

"Build in the incentives. If I can improve the health status and drop the total cost -- if I'm on the hook to do that -- hold me accountable. And incentivize me."

And he wants a system that takes into account the social complexity of the clientele for whom we provide services and partner with. "If you pay only for the services, the incentive is for health care providers or organizations to skim the relatively healthy, and avoid or underserve the high-need, high-complexity cases. "It's got to be calibrated... if that isn't built in, you're screwed."

In short, he wants a world which enables him to deliver culturally-sensitive, economically-efficient, integrated health care that addresses the physical, emotional and spiritual needs of individuals, families and communities. Tall order, but he's already started.

HEALTH REFORM: What Works (The Real Reality TV)

Joanne Kenen — Thu, 10 Sep 2009 18:26:00 -0400

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.

And, we were happy to see, it's got some bright young doctors who are very gung-ho on health reform. As newly minted MD Mike Wilson (unless he's changed his last name since last night) put it, "I think it's finally come to the point where we realize something has to be done about this health care system."

Mayo is not alone. More hospitals and health care systems are moving toward a more integrated approach, improving quality -- while lowering costs. Changing our payment system to reward, not stifle, such innovation is part of health reform too.

PBS for instance recently profiled the Billings Clinic in Montana (part of our Health Care CEOs for Health Reform). They looked at how quickly patients get treated, how closely the doctors work together, and how Billings strives to keep elderly patients out of the hospital, sometimes with telemedicine that lets them be monitored at home, heading off crises before they happen ... and require another trip to the ER.

DR. JORGE NIEVA, oncologist, Billings Clinic: Care here is very patient-centered. Patients get brought here, and we try to arrange for them to see everybody that they need to see in a very rapid period of time. It's a collaborative model. It's a model where I can always call up the doctor down the hall or walk across the hall and get him to see somebody the same day, if they need to be seen that day for a serious illness or diagnosis.

CBS profiled Virginia Mason in Seattle, another member of the Health Care CEOs group. One thing Virginia Mason has become well known for (and we've written about it before) is working closely with Seattle-area businesses to figure out what their workers need. One result: improved treatment of back pain. Patients get treated more quickly -- and more inexpensively. And they get well faster. They showed one patient who was in the clinic getting physical therapy within two hours of her initial call. No waiting days or weeks for a specialist. No unnecessary expensive imaging. Good treatment. Fast treatment. Cost-effective treatment.

QUALITY: House Calls Make a Comeback For Frail Elderly

Joanne Kenen — Tue, 18 Aug 2009 13:29:00 -0400

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."

At a patient's home, Dr. Zafirau gets a picture that is both fuller and more nuanced. He can see when a patient is having trouble managing multiple medications, when medical equipment hasn't been delivered, when a patient cannot navigate safely around his or her own home. "I don't even have to ask. I can see with my own eyes," he said.

The house call program is one of several innovations that Summa has undertaken in the past 15 to 20 years to improve care of patients who are frail, elderly and/or chronically ill. Well-coordinated care is also often less expensive care. More communication. Less duplication. Fewer crisis. Shorter and less frequent hospitalizations.

But in our fragmented fee-for-service system, where various health providers' and payers' interests are often at odds, this kind of model doesn't always work. Home visits and other time-intensive ways of managing and treating the chronically ill -- more face time, fewer tests and procedures -- doesn't make financial sense for physicians working in a fee-for-service environment. (It often doesn't work for the hospitals either.) In our current system, efficiency isn't always compatible with the bottom line.

But Summa has been moving toward becoming an integrated system -- a health system that includes a health plan (for profit), hospitals (nonprofit), a hospital-physician organization, and related resources in the community. It isn't totally integrated yet. But it's on its way, both because Summa has figured out how to make it work economically and because its leaders have a mission. To get where they really want to be, though, they need the incentives changed in the system, new tools to let them become fully integrated, to be an "Accountable Care Organization."

In other words, they need health reform.

"We've been working on all these pieces and parts to bring about integration," including research, teaching and community partnerships, said Dr. Kyle Allen, chief of the division of geriatric medicine and Summa Health's medical director of post-acute and senior services.

"We've built the infrastructure," Dr. Allen added. " Now we're waiting for health reform to give us the right incentives."

The Summa home visit program began about three years ago. It joined a list of Summa programs -- including geriatric rehab units, geriatric intensive care units, a stroke unit, and a transition program developed with area nursing homes -- aimed at the frail elderly. Interdisciplinary teams, trained in geriatrics, focus not only on keeping a heart pumping or the lungs breathing but on minimizing a patient's functional decline. Not all the data has been collected, and not all of it's public (though some has been reported on the AHRQ website here and here.) They haven't reached all their goals, like reducing hospital readmissions across the board as much as they would like. But "the trend lines are in the right direction," Dr. Allen said. Overall, Summa reports that its costs are lower than the national average, outcomes are better, and the health quality cognoscenti are beginning to take note.

Dr. Zafirau's home visits serve about 150 patients with one (usually more) of four conditions -- congestive heart failure, COPD, recurrent aspiration pneumonia, and diabetes. Many also have dementia, depression or both. All have limited mobility and need help taking care of themselves. About half are dual eligibles -- old and/or disabled enough to quality for Medicare, poor enough to quality for Medicaid -- and part of an Ohio Medicaid waiver program aimed at providing home and community based care instead of nursing homes.

"We are trying to help some of the people that were high utilizers [of health care] but underutilizers of ambulatory care," Dr. Zafirau said. In other words, they wanted to better serve patients who frequently saw the doctor -- but only in the hospital. A geriatrician or nurse practitioner sees each patient at home about once a month -- more if needed, sometimes less if the patient is very stable. They can provide services that are often not available outside a hospital or clinic -- immunization, x-rays, ultrasounds, IV fluids, what Dr. Zafirau calls "one-stop shopping for most of their medical needs." Social workers and nurse care managers are also closely involved; the medical and social services are entwined, which is not always the case in other systems. Mrs. S, for instance, not only has her breathing and arthritis better managed; she's visited by home health aides, and attends an adult day program once a week, alleviating her isolation.

Dr. Zafirau says surveys show a very high patient satisfaction, with almost all rating the home care program as excellent or very good. The patients aren't the only happy campers.

"I am happier, " said Dr. Zafirau. "I spend more time with my patients, I get to know them more as people. For me that's a positive."

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

Joanne Kenen — Thu, 30 Jul 2009 20:16:00 -0400

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.)

The city several months ago brought in Dr. Joanne Lynn, a nationally-known clinician, writer and researcher.

Dr. Lynn is an articulate champion of dragging health care into the 21^st century and making the system respond to the needs of patients. She wants to start with Washington DC. Not in another 20 years. Now.

She now heads the Chronic Care Initiative in the city's department of health. So far the city has allocated $10 million in tobacco settlement money to the health initiative. About a dozen programs are underway; more should come on line later this year and next.

It's an ambitious project, basically taking the lessons of quality improvement and the goals of population health and applying them across an entire city with an unhealthy population and a fragmented health care system that in its current form is not conducive to managing chronic illness. The Chronic Care Initiative is, in essence, an attempt to reinvigorate primary care (and common sense) in Washington, and to apply city-wide what quality improvement wonks called the Triple Aim goals:

1) Improve the health of the population

2) Enhance the patient experience

3) Get Value

That's a tall order in the best of circumstances. Here they are trying to achieve the Triple Aim for an unhealthy population that includes lots of people who are poor, sick, and members of racial or ethnic minorities.

The initiative involves several of the city's big teaching hospitals as well as smaller clinics and mental health centers. Dr. Lynn calls them the pioneers. They are starting small, reaching finite numbers of patients in specific clinical and community settings. But they are aiming high.

The programs aren't occurring in isolation, one in this clinic, one in that hospital. They are part of a collaborative, designed to share knowledge (failures and missteps as well as successes) and to try to knit Washington's very fragmented health care system into one that can better coordinate care. If you can tolerate a really mixed metaphor, they are trying to weave "silos" of care into a community-wide tapestry of care (with primary care at the core). The goal isn't just to lower the blood sugar of a few hundred diabetics, or to get a hospital in a poor neighborhood to alert the nearby community clinic when a patient shows up in the ER. The goal is to make Washington healthier while getting more bang for the health care buck.

Through Dr. Lynn, I've had a chance to meet some of the doctors and nurses, social workers and translators, running these chronic care pilots. During the coming months, I hope to write about them more in depth. They include:

Putting a nurse-practitioner into a mental health clinic, because people with severe mental illnesses tend to have other chronic disease that often end their lives prematurely.

Enabling diabetics to do self-care through applications on their cellphones. (First you have to make sure they all have cellphones, and the cellphones are compatible with the health software).

Turning an ER crisis visit into a teachable moment, by making sure a diabetic gets to a patient-educator before leaving the hospital.

Doing a better job of treating HIV-positive people who also have chronic heart or kidney disease, trying to figure out why sicker and more complicated patients are less "compliant" about medication and appointments than healthier ones.

Setting up computer health kiosks in community centers in low-income neighborhoods where people may not have the latest laptop technology at home. (And to make sure they know how to use the technology).

Improving health information technology citywide, so all doctors treating a patient can get a full picture, no matter what clinic or center or hospital the patient turns up at.

Addressing high rates of hospital readmissions by some simple steps like having the hospital notify a community clinic when their patient shows up. (Early attempts to address this seemingly simple task have been frustrating and slow).

I hope the "pioneers" are open about their failures as well as successes; because failures hold lessons too, and they can lead to success. What needs to be tweaked, what needs to be scrapped, what needs to be looked at from a fresh angle. No sense in Clinic A learning that such and such an approach doesn't work, without making sure that Clinic B doesn't go down that fruitless road itself in another year. That's part of the "collaborative" as Dr. Lynn has designed it. Every few months, they all get together and swap stories, share insights. They learn.

This isn't the health reform that's being discussed on Capitol Hill. But comprehensive national legislation -- expansion of coverage, re-alignment of incentives, emphasis on primary care -- all those elements will make it easier for this initiative to achieve its goals, to lead the way. But the national legislation is, to a certain extent, about money and financing, the backbone of health reform. The work going on in this city may prove to be its heart and soul.

QUALITY: When Medicaid Gets Health Right

Joanne Kenen — Thu, 09 Jul 2009 15:20:00 -0400

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:

One is the evidence that basic delivery changes have the potential to make a difference and produce savings. This is not cutting edge or controversial comparative effectiveness research or complex payment reform; it's basic, sensible care management with the delivery system and data system changes necessary to make it happen. I suspect a number of variations on this approach could be effective depending on local circumstances. The key is providing a usual source of care and truly managing care for those who need it most, whether that is called "primary care case management" as it was 25 years ago, or an "enhanced medical home" as it is in North Carolina.

A second message is that Medicaid, often characterized in public debate like other public programs as lagging behind the private sector in its ability to innovate, can be a leader in demonstrating how to improve care and lower costs through delivery system changes.

A third message is about the importance of focusing efforts on the sickest, highest cost patients, because they have the greatest health care needs and account for such a substantial share of health care spending. A small percentage of the U.S. population (five percent) accounts for nearly half of health care spending. If we want to get a handle on increases in spending in Medicare and Medicaid, we will need to do more to reach out to and more effectively manage care for these high cost groups.

Other states are putting some of these lessons to work; Indiana, for instance, has been doing a lot on chronic disease management for its Medicaid population. And some community health clinics, like the Urban Health Plan in the Bronx we wrote about earlier this year, have learned as North Carolina has that you can provide a lot better care to poor people when social workers team up with the medical staff to address the context as well as the complications. That's often not the case, another example of penny wise, health care system foolish.

One last comment. There is a certain amount of urban myth -- I haven't seen it in writing, but I've heard a lot of offhand remarks in health policy settings -- that the North Carolina program is working because it's only treating healthy kids. That's not the case. It's treating some healthy kids -- and it's enabling some kids stay healthy. But it's also treating people with serious chronic illnesses. And it's doing a very good job.

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

Meredith Hughes — Wed, 10 Jun 2009 16:09:00 -0400

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.

Access is also a problem. Low-income people and minorities are much less likely have insurance. Of the approximately 46 million uninsured, about half are poor and one-third suffer from chronic disease. Even for those with access to care, the care is less consistent. Disjointed, inconsistent care frequently leads to poorer health, and for those with chronic disease, a lack of routine care and prevention can lead to costly emergency room visits and more serious health problems. Low-income Americans are three times less likely to have a consistent source of medical care.

Minorities are less likely to receive routine screening for cancer. That means when the disease is finally detected, it is in a more advanced and often fatal stage. Low-income women are 26 percent less likely to have a mammogram. Vietnamese women are about half as likely to get routine pap smear for early detection of cervical cancer—and Hispanic and Vietnamese women experience cervical cancer at twice the rate of white women. The White House addressed the health care problems faced by women in an earlier report, Roadblocks to Health Care.

These disparities are only growing worse in the current economic crisis, underscoring the importance of health reform that is affordable, accessible, and emphasizes comprehensive, preventative care for everyone. Recently, the Kaiser Family Foundation has taken a look at state and national health disparities in terms of gender, race, and ethnicity. We'll post on the briefing, Putting Women's Health Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level, later this week. As Secretary Sebelius said in a press release,

Minorities and low income Americans are more likely to be sick and less likely to get the care they need...These disparities have plagued our health system and our country for too long. Now, it's time for Democrats and Republicans to come together to pass reforms this year that help reduce disparities and give all Americans the care they need and deserve.

HEALTH REFORM: A Call for Precision

Health Policy — Wed, 03 Jun 2009 15:00:00 -0400

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?

Medical homes (which mean very different things to different health system change advocates) can help care for people with chronic conditions. The emphasis on wellness and care coordination, on education and intervention, can help prevent people from developing these conditions, and or can keep people stable and living fairly healthy normal lives for quite some time even when they do develop these diseases.

But what about patients with cognitive deficits and difficulties with the activities of daily living? That's a different category. Can they even, physically, get to their medical home? Or does the medical care have to come to the patient's home? What if a patient has five diseases and is homebound for all intents and purposes but doesn't qualify for home health services under Medicare and isn't on Medicaid?

We also tend to talk about primary care as the focus for care management. But for someone with progressive Parkinson's, the patient will surely be seeing a neurologist as the principal care physician for that condition. Should the neurologist also be the care coordinator or should we be more explicitly defining co-management of patients? Or a nephrologist or a dialysis center where the patient goes three days a week for someone with kidney disease? Most older people with one chronic disease do in fact have others, and their care is complex and demanding.

There is no Holy Grail; we'll probably need different solutions for patients at different points in their disease trajectories. So far, we have not provided rigor to discussions of chronic care coordination, assuming somehow that the same model should apply regardless of which chronic conditions are under consideration. We have a lot to do; it will be easier if we can all agree on what we are talking about.

COST: Industry Groups Outline Cost-Savings Initiatives

Joanne Kenen — Mon, 01 Jun 2009 22:23:00 -0400

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).

Individually and together, our organizations have developed initiatives that will help move the nation toward achieving the Administration's goal and we intend to keep working. Our organizations will now pursue these initiatives which, together,will help transform the U.S. health care system.

So while this is certainly a step in the right direction, giving more oomph to the cost-down, quality-up message, it remains to be seen exactly who is committed to doing what when, and what legislative steps, regulation, timetables or mandates the industry will or will not embrace. Guess we'll find out later this month when the rubber starts to hit the legislative road...