Chronic Disease

QUALITY: "Lucky 13" Policy Wonks Map Out Path to Health Quality

Julie Barnes — Tue, 13 May 2008 14:23:00 -0400

A lucky 13 top-notch health policy wonks outlined concrete and achievable stops to improve quality, reduce cost, and repair our health care system in the May/June issue of Health Affairs. For instance, beyond the common refrain for increased use of "evidence-based" medicine, the "Quality Crossroads Group" called on Congress to immediately create a national center to support effectiveness research so we can at least get started on examining what treatments work best and when to administer them.

We also liked the call by the authors, including New America's Len Nichols, to replace the fee-for-service payment model with systems that reward clinically effective and efficient population health management--like bundled chronic care episode payments and paying for population health performance.

As we continually say in this space and elsewhere, successful reform must address coverage, costs and quality at the same time. This Quality Crossroads Group outlines better and more succinctly than most how quality improvement, cost containment, and coverage expansion are inextricably linked. Ultimately, the group offered five ways to achieve a high-performance health system:

Create a national center for effectiveness research.
Develop models of accountable health care entities capable of providing integrated and coordinated care.
Develop payment models to reward high-value care.
Develop a national strategy for performance measurement.
Pursue a multistakeholder approach to improving population health.

To be succinct, we agree.

QUALITY: Taking Care of the Boomers

Joanne Kenen — Mon, 14 Apr 2008 17:47:00 -0400

More bad news for those of us who plan on getting old some day. The Institute of Medicine just released Retooling for an Aging America: Building the Health Care Workforce which reminds us there are not going to be enough doctors and nurses to deal with the geriatric needs of the 78 million baby boomers who start reaching age 65 in 2011. The authors said Medicare, Medicaid, and other health plans should pay higher rates to encourage more docs to learn about geriatrics. It also recommended training for family members and other aides who do a lot of the heavy lifting (literally and metaphorically) for the elderly. In many parts of the country, it noted, dog groomers and manicurists are required to get more training than the people who take care of our seniors.

"We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably," said committee chair John Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City.

This isn't the first report to remind us that geriatricians are underpaid relative to other specialties. A geriatrician earned $163,000 on average in 2005 compared with $175,000 for a general internist—even though the geriatrican has extra years of training. (Neither of them earn as much as many specialists.) Registered nurses who work in nursing homes or other long-term care facilities typically work more hours but earn less than nurses in other settings. Remember that the Boomers can be expected to age (and die) differently than earlier generations. They will live longer and many will live healthier, but they will also have multiple chronic diseases. Today, the report said, the typical 75-year-old has three chronic conditions and takes at least four prescription drugs. Someone has to coordinate their care.

The IOM recommended that ALL health care providers get some training in geriatrics as virtually all of them (OK, not the pediatricians) will treat at least some elderly people. The report considered too whether we need to rethink some of the roles and responsibilities of providers. Maybe we should allow a certified nursing assistant to administer some medications, freeing the R.N. to manage the more complicated needs of a chronically-ill elderly patient.

The report said Medicare needs to improve what it pays, and change its focus from short-term, acute crises to managing chronic and age-related conditions. Lawmakers are beginning to get that message. Last week, it was reported that Senate Finance Committee Chairman Max Baucus (D-MT) wants to beef up Medicare payments for primary care in the doctors' pay package he's working on. Whether the specialists go for that remains to be seen.

COST: Disease Management or Smart Spending?

Joanne Kenen — Tue, 08 Apr 2008 16:59:00 -0400

Earlier today we put up a guest post by Robert Berenson of the Urban Institute on the troubles with a Medicare pilot program on disease management. Here's another interesting take by Gooznews' Merrill Goozner. Merrill doesn't rule out the value of (good) chronic disease management, perhaps through medical homes, but he also shares our belief that we need a lot more comparative effectiveness research so we know how to spend our health care dollars more wisely:

To squeeze out short-run savings to cover the uninsured, government programs need to develop a strategy to eliminate some of the wasteful use of drugs, procedures and tests that now permeate the system. There's a growing consensus to set up a comparative effectiveness agency in the U.S. to combat that waste. But even this long overdue reform can run off the tracks if it isn't done the right way, an issue I'll address later this week.

Our colleague Tom Emswiler has also posted on the emerging consensus around comparative effectiveness, and he'll address it again too.

COST: For Disease Management, the Doctor Must Be In

Joanne Kenen — Tue, 08 Apr 2008 14:54:00 -0400

When we saw Monday's New York Times report on how Medicare's experiment in disease management was not cutting costs, we asked Robert Berenson MD, Senior Fellow at The Urban Institute, to comment. Here's what he had to say:

Disease management for patients with chronic conditions is supposed to pick off the "low hanging fruit" of cost containment, both in Medicare as well as among self-funded private employers and commercial health insurers. In each of these settings, about 5 percent of subscribers/beneficiaries are responsible for more than 40 percent of the health costs, and 20 percent of the patients run up 80 percent of the costs. Many of these patients have one or more underlying chronic conditions, such as congestive heart failure (CHF) or diabetes.

Surely, the thinking goes, we can easily find savings by applying better management techniques. We can use telephone or web-based communication tools for better surveillance. We can teach patients self-management skills. And we can do all this, the thinking went, without having to interfere with the physician-patient relationship. Indeed, presidential campaigns typically assume substantial savings from disease management-type initiatives targeted to the high spending associated with patients with chronic conditions.

Based largely on anecdotal reports of great success by third-party disease management vendors and effective lobbying, Congress in the Medicare Modernization Act of 2003 commissioned a pilot test of disease management for patients with CHF and diabetes. Unfortunately, as the New York Times April 7 article by Reed Abelson, "Medicare Finds How Hard It Is to Save Money" documents, this three-year pilot failed to save money.

Every once in a while a seasoned (or crotchety) policy analyst gets to say, "I told you so." And it's my turn to say it now. Shortly after this Chronic Care Improvement (CCI) pilot was authorized, I testified before the Ways and Means Subcommittee on Health, warning the lawmakers that business techniques could only go so far in managing disease without the involvement of doctors:

"Although the CCI program may be a good start, in my opinion it is insufficient for truly addressing chronic care needs in Medicare because it lacks a focused physician component. The Administration emphasizes that the new program creates a 'business platform' that will permit innovation, but the CCI program ignores the reality that beneficiaries look to their personal physicians for responsibility for their health care—and not business platforms—whether health plans, disease management companies, or other third-party vendors."

Some elements of the disease management industry say the pilot failed to save money because CMS implemented it poorly. It's more likely that the failure belongs more with the "physician bypass" logic of the approach. Implementation problems notwithstanding, if this approach cannot achieve robust savings on congestive heart failure—the "poster child" of a condition responsible for avoidable, expensive hospitalizations and supposedly amenable to disease management interventions—one has to question whether it can possibly work to reduce spending for patients with assorted other chronic conditions. In fact, some disease management companies now are exploring how to change their approach to become an extension of the physician's office, rather than primarily an external party trying to engage the patient.

For more than 30 years Medicare has tried and failed in many other demonstrations to reduce costs associated with frail elderly and non-frail seniors with multiple chronic conditions—but without the direct involvement of patients' physicians. It is time to try to include, rather than bypass, physicians in chronic care management and coordination. That is where the so-called "patient-centered medical home" comes in. But that is another story.

(New America's Health Policy Program director Len Nichols and Berenson are co-directing a study on Medicare reform, specifically about how to make Medicare a value-based purchaser. They will release their first round of papers this July.)

COST: End-of-Life Spending Can Boost Bills Without Extending Life

Joanne Kenen — Mon, 07 Apr 2008 18:35:00 -0400

In the last two years of life, patients at some top academic medical centers spent more time in the hospital, had more doctors' visits and cost Medicare way more money than patients at equally esteemed top medical centers. But the higher bills didn't bring them longer life. In fact, patients with the more intensive and expensive treatment tended to die slightly sooner, according to the latest research on chronic disease and end of life spending from the Dartmouth Atlas.

The Dartmouth Atlas now has published huge amounts of data pounding home the message that more isn't always better. Doctors and patients haven't yet gotten the message across the board, and the way our health care system (Medicare and much of the private sector) pays doctors and hospitals encourages more and more volume.

"Higher spending doesn't lead to better quality or outcomes," Dr. Elliott Fisher, director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practices told a teleconference. "We continue to be surprised by the differences in practice." But if the most intensive and expensive hospitals adopted the practices of the high-quality but lower-spending centers, Medicare could save some $50 billion a year.

The Dartmouth team, for instance, compared UCLA and the Mayo Clinic, both excellent centers with sterling reputations. Four salient points:

Spending—UCLA spent more than $93,000 per patient over the last two years of life. The Mayo Clinic, by contrast, spent $53,432-a little more than half the amount of UCLA on similar patients during the same period of time.

Utilization—Chronically ill patients in their last six months of life had more than twice as many physician visits at UCLA compared with Mayo, and they spent almost 50 percent more days in the hospital.

Resource Use—Compared to the Mayo Clinic, UCLA uses one-and-a-half times the number of hospital beds, and almost twice as many physicians to manage similar patients.

Medicare—indeed, much of our health care system is designed for a bygone era. People had acute diseases, and then they died. Now people live for years with chronic disease or diseases. More than 90 million Americans live with at least one chronic disease, and seven out of 10 Americans will die from one.

The folks at Dartmouth aren't just pointing to statistics. They have an action agenda. Here are a few of their ideas:

Science aimed at establishing the best treatments, settings and use of resources for the chronically ill, and then payment systems to bring behavior in line with those findings. "The nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient's wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care."
More organized integrated systems of care, like the Mayo model which uses fewer resources to achieve high quality care.
Medical homes—where a team of primary care practioners manage chronically ill patients—have promise but they need to have good and efficient collaboration with specialists.
Shared savings. Transforming the payment system away from volume and toward quality and outcomes could take a decade or more. In the meantime, providers (doctors or hospitals) should be able to share the savings if they improve coordination and reduce overuse. That way efficent doctors are rewarded.
Given that they've been issuing similar reports for years without seeing enough ripples through the system, the Dartmout team was upbeat. "We may be near a tipping point," they concluded in their report. From their vantage point in Hanover, and ours here in Washington, we can see policy makers beginning to think about how to link smart spending with quality care.

The Atlas's discussion about primary care and medical homes has already prompted some discussion. The Health Affairs Blog, for instance, Rob Cunningham sees the Atlas report as "a roadmap to medical homes." He notes that not everyone has the same definition of what a medical home is or should be, whether it should encompass all general practioners who take on care coordination or a more sophisticated capacity targeted at the patients who use the most medical services. He writes,

"The Dartmouth finding that 'simply increasing the number of primary care physicians alone will not improve coordination' is an important contribution to a growing policy debate about medical homes. If a new national policy conversation about health reform does in fact occur in the wake of next November’s elections, there may be an opportunity to consider delivery system organization as a basic element, along with cost and coverage. A magical, payment-driven transformation of the delivery system into integrated entities cannot be assumed to be inevitable, as it was in the early 1990s. If there’s going to be real change, it will have to be organized from the ground up. The new Atlas ought to be an invaluable navigation aid to the next wave of pioneers. Perhaps the next step is to understand how primary care works in low-spending areas."

We've been posting quite a bit about chronic disease management lately, and we asked The Urban Institute's Robert Berenson to chime in. We'll post his thoughts here on Tuesday.

QUALITY: Physicians Healing Thyselves (or at Least Their Offices)

Joanne Kenen — Thu, 03 Apr 2008 20:45:00 -0400

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

But here's our basic takeaway on how the 9^th annual summit on Redesigning the Clinical Office Practice, run by the Institute of Healthcare Improvement, could contribute to the high quality, cost-efficient and caring health system we envision for the future: as we noted when we posted on former Gov. John Kitzhaber's keynote on Monday, IHI and its CEO Dr. Donald Berwick (pictured) get a ton of (well-deserved) attention but mostly for what they are doing in the inpatient world, fighting hospital-acquired infection, developing rapid response teams and the like. (Yes, for any health policy newbies among our readers, IHI is the make-doctors-wash-their-hands-and-send- their-ties-to- the-cleaners-now-and-then" group.) Maybe figuring out how to apply "queuing" theories that work in supermarket checkouts and LEAN business practices to outpatient primary care isn't as sexy to the headline writers but it's just as important. Reducing wait times— waiting time to get the appointment and then all the time we sit around in waiting and exam rooms—isn't just a matter of convenience. It's about reducing waste, freeing up time and resources so people get the care they need, when they need it.

There was lots of talk about electronic medical records (one session was called "Going Digital Without Going Bankrupt") but a lot more talk about patients. How to streamline office practices so instead of having three nurses answering the phones you can have two on the phones and the third working one-on-one with a chronically ill patient, keeping them out of the hospital. How to create a "medical home," where a patient's care is truly coordinated by a primary care team that knows the patient instead of fragmented care by a half- dozen specialists flung across various clinics and hospitals, none of whom knows what the other is doing. Dr. Carole Redding-Flamm, executive medical director of Blue Cross Blue Shield Association, described Patient-Centered Medical Homes that are up and running in several states, rural and urban. The insurers, in some cases, are paying the doctors extra for successfully managing the care. An extra benefit, doctors report, is higher rates of patient satisfaction.

One high risk time for patients is transitions, for instance from the hospital to home health care. It sounds like a no-brainer to say that sick, frail people at high risk of finding themselves back in the hospital within a month need more than an occasional visit from a home health aide. But in reality, that's sometimes all they get. Consultant Ann Hess described a pilot program between Mt. Sinai Hospital in New York and the Visiting Nurse Service of New York. She showed how getting a nurse practitioner to a home-care patient soon after leaving a hospital reduced the rehospitalization risk. But that required tools for assessing the risk so that the nurse practitioner (who costs more than a less skilled home health aide) goes where she is really needed. It also requires getting the patient to see a doctor after a high-risk hospitalization within seven to 14 days (which often does not happen - that's where the smart business practices and reduced waiting time makes a big difference to the quality of care).

The "reinventing clinical practice" concept is an exciting one to anyone who has spent years in Washington (where all too often policymakers reinvent stalemate). One thing we'd like to see happen in this blog is for policymakers to hear about clinicians who are creating change, and for clinicians to understand how policymakers are beginning to understand some of the linkages between cost, quality and coverage. If you know any "clinician innovators" with good stories to tell, please post a comment and let us know.

COVERAGE: Can "Concierge Care" Cure What Ails the Poor?

Joanne Kenen — Wed, 02 Apr 2008 16:48:00 -0400

The terms "concierge medicine" "Palm Beach" "poverty" and "free medical care" don't necessarily go hand in hand but a group of Florida "VIP" physicians are starting an interesting initiative aimed at showing that close doctor-patient collaborations with an emphasis on wellness and good management of chronic disease can work for the poor and sick, not just the rich and healthy.

Now we aren't advocating charity as the solution to the nation's 47 million uninsured (although we sure don't object to helping people out until we get a comprehensive national solution) but we do like good management of chronic diseases before they become acute crises. The pilot program described by the South Florida Sun Sentinel and brought to our attention by Health Leaders Media is intriguing.

The newspaper reports that Project Access, a Palm Beach County Medical Society program that connects patients to free care, is teaming up with MDVIP, a concierge practice, to take care of 25 very low-income people, and they hope to expand it to cover several hundred. It's being paid for by a mix of volunteer labor and subsidies from the medical society.

In a concierge practice, patients pay a yearly fee to have access to their physician. The physicians in turn take on far fewer patients, meaning they have more time to spend with their patients than the rushed office visits that have become all too common. According to this report, members of this concierge practice pay $1500 to $1800 a year to join.

The doctors in this pilot care project aim to show that their way of practicing medicine, with its emphasis on wellness, communication and web-based medical records, is efficient and cost effective. Pilot group patients are uninsured and are at 200 percent of the federal poverty level: $20,800 annual income for an individual or $42,400 for a family of four. The medical society sought participants who are ages 45 to 63 with chronic conditions, such as diabetes and hypertension.

"Our style of medicine results in fewer hospital and emergency room visits," Ed Goldman, MDVIP chief executive officer, told the Florida paper. That saves money.

With the U.S.population growing older (and fatter) chronic disease is a huge challenge for the U.S. medical system and we aren't meeting it well. Many estimates, including work by the Dartmouth Atlas, show that chronic care eats up about 75 percent of the nation's health spending. We don't spend enough on prevention and management, meaning we end up spending way too much (and unwisely) on crisis care. Palm Beach concierge medical practices won't be the answer for the nation as a whole, but if they've got any lessons to teach us, we're listening.