Chronic Disease

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:

It is not every day the U.S. loses to the Dutch. Heck, even when our wooden-shod friends were favored in soccer over the U.S. in group play at the Olympics this summer, the U.S. came from behind to tie.

But when it comes to the quality of health care services, particularly taking care of people with chronic disease, the Netherlands runs way ahead of us.

So do Australia, New Zealand, France, Germany, the United Kingdom and Canada.

The Commonwealth Fund and Harris Interactive's 2008 survey of access and efficiency of health care services offered to chronically ill adults in eight industrialized countries provides yet more evidence that we in the U.S. do a terrible job of caring for patients with ongoing conditions. Despite far outspending the other seven countries surveyed, and despite high cost sharing even for insured patients, the U.S. was the hands-down survey loser. It's another reminder that our anachronistic system is designed to respond to acute, episodic illnesses, not prevent complications or deterioration of patients with chronic conditions.

The folks over at the Center for American Progress believe, as we do, that health reform is about more than making sure people have insurance. It's about retooling our health care delivery system so that it provides high quality care, spends health dollars sensibly, addresses chronic disease, and promotes public health. (In the unlikely case that you need any reminder about the chronic disease and public health messages, check out the CDC report that the diabetes rate has nearly doubled in the U.S.)

There are lots of ideas about how to repair our health care system. We write about them a lot, and MedPac has pulled a lot of the ideas together in its own reform roadmap for the elderly. CAP pulled together some of its own health experts as well as some other think-tankers and policy types to try to further braid the strands of these reform ideas. The result is a new book, The Health Care Delivery System: A Blueprint for Reform. You can download it here, and or read the Overview and Recommendations. We haven't read the whole book yet (although in the past we've spoken with and blogged about quite a few of the contributors), but here are a few key points from the summary:

Dr. Glenn Steele, the president and CEO of Geisinger Health System, recently co-authored an article in Health Affairs and appeared at a Health Affairs forum here in DC to talk about the innovations at Geisinger, and the ways that Geisinger's unique characteristics might limit their adaptability elsewhere. Geisinger is both a health plan and a health network spanning 41 counties in Pennsylvania, and it has an unusual mix of Geisinger and non-Geisinger physicians, of open-and closed-staff facilities. It is blazing trails on many fronts, in chronic and acute care, from medical homes to its ProvenCare initiative for certain acute inpatient conditions and procedures.

We spoke with Dr. Steele recently and turned his question around. We weren't so much interested in the limits of Geisinger's example; we wanted to know what would work elsewhere—which of those trails could be followed or adapted by others. To our relief, Dr. Steele told us that other hospitals and policy experts have been flocking to Pennsylvania recently trying to answer that precise question. And the answer is that quite a bit of it would work elsewhere.

More evidence that it's not just the uninsured clogging up our ERs. It's the whole flawed health care system clogging up the ERs.

A study in the Journal of the American Medical Association, described in USA Today, shows that emergency room crowding has multiple causes. Yes the uninsured are part of the problem, and in some cities they are a big part of the problem, but typically the uninsured try to avoid ERs because they are so expensive.

We've mentioned Community Care, North Carolina's innovative Medicaid program for chronic disease management, briefly in the past but today's News and Observer takes a detailed look. Community Care has been shown to save money —and improve the quality of care for Medicaid patients with conditions such as diabetes and asthma. The savings are impressive—$100 million a year, or $2 for every $1 the state spent on the program, which covers 810,000 Medicaid patients in "medical homes" through 14 nonprofit networks around the state.

The patients are monitored closely, so that conditions are kept in check and complications and hospitalizations are minimized. Case managers work with physicians and other providers, hospitals, public health and social service agencies to coordinate comprehensive care and make sure that patients don't fall through the cracks and that transitions—say after a hospital admission—are handled smoothly. Doctors get paid a fee to compensate them for the time-consuming aspects of care coordination and management that are often go not reimbursed.

Here's a classic half-full, half-empty health care scenario.

Some hospitals and communities are vastly improving the way they take care of seriously ill patients.

Some aren't.

The Center to Advance Palliative Care and its close collaborator the National Palliative Care Research Center recently completed a "report card" complete with interactive maps on palliative medicine nationwide. Despite the growth of palliative medicine as a field in recent years, they found large variation in access and quality. Only three states—Montana, New Hampshire and Vermont—got an "A." Overall, the country got a "C." Generally speaking, the South and portions of the West lag in palliative care. In Mississippi, for instance, less than 10 percent of hospitals have a palliative care program; in Vermont every single hospital has one. Big hospitals are more likely than small hospitals to have palliative care, for-profit hospitals were less likely than nonprofits (even though these two research groups have found that palliative care is cost-effective), and safety net public hospitals which serve large numbers of the uninsured also tend to lag.

While our colleague Paul Testa was going through the latest numbers on the incredibly shrinking primary care work force, we were over at the Health Affairs session listening to Robert Berenson of the Urban Institute talk about how to build the Medical Home, which is in some ways a souped up 21st century version of primary care.

Bob (who has guest blogged for us in the past) said a lot of docs don't like primary care in our current world because of what he called the hamster syndrome. They feel like they are hamsters spinning on wheels in a cage, unable to keep up, unable to move ahead. The medical home is supposed to restore primary care's rightful place in the healthcare universe, while as Berenson wrote in the current issue of Health Affairs, "providing a source of confidence, advocacy, and coordination for patients as they encounter the disconnected parts and often daunting complexity of the health care system." Advocates of medical homes stress their importance in managing chronic diseases. Naturally, to make them work, we're going to have to pay primary care providers better and differently if we want care coordination and oversight to replace piecemeal, pay-for-procedure medicine.

The Hispanic population in the U.S. has more than doubled in the past 15 years, to around 45 million. But it is an increasingly heterogeneous population. The Pew Hispanic Center and the Robert Wood Johnson Foundation decided to find out more about how Hispanics access health care, where they get their information and what they know—particularly about chronic diseases such as diabetes.

The survey found that more than one-in-four Hispanic adults in the United States lack a usual health care provider (other than the E.R.) and a similar number reported obtaining no health care information from medical personnel in the past year. In fact, they were more likely to get their health information from television.

I've been doing a lot of traveling, attending meetings about health care quality and payment reform, and I wanted to share a bit of what I learned at the recent Healthcare Payment Reform Summit in Pittsburgh. The topic was "bundling"—paying for an episode of well-coordinated care. In the current system, we pay for quantity of procedures, not quality or outcome.  Everybody at the Pittsburgh summit understood that this procedure-focused system leads to overutilization of care.

Moving from the status quo to bundling will take some careful planning and transitioning, but Francois de Brantes gave a presentation that underscored how worthwhile it can be. He presented data showing that improved management of diabetes and heart disease leads to better quality—as well as a 50 percent drop in costs.