Chronic Disease

MedPAC's big June report is out, and it's full of big June ideas. Really big ideas. The panel, which advises Congress on Medicare policy, outlines (not all for the first time, but more emphatically and comprehensively) a lot of ideas for changing a lot more than technical fixes to fee scales and payment rates. MedPAC is ready for the whole enchilada (or whatever the geriatric equivalent would be. Chicken dumplings?) in reshaping the system so that it is both higher quality and more cost-effective. The nonpartisan panel of experts wrote:

Fundamental changes are needed in health care delivery in the United States and in Medicare. ... Recent studies show that the U.S. health care system is not buying enough of the recommended care, is buying too much unnecessary care, and is paying prices that are very high, resulting in a system that costs significantly more per capita than in any other country.

Medicare does more than take care of the elderly and disabled. It sets patterns and models for much of the U.S. medical system, affecting how hospitals function and doctors practice. It also costs a lot. The commissioners stated further:

We mentioned bank robber Willie Sutton earlier this week in our initial recap of the Partnership to Fight Chronic Disease's recent policy symposium. Sutton was one of the first criminals on the FBI's Ten Most Wanted Fugitives list. We heard another infamous list during former Senate Majority Leader Tom Daschle's symposium keynote speech when he listed the major myths standing in the way of health reform. His top three:

When asked why he robbed banks, Willie Sutton supposedly said "because that's where the money is." Ask health reform advocate Ken Thorpe why he spends so much of his time on chronic disease and he'll probably tell you the same thing: that's where the money is—about $1.58 trillion according to the CDC.

Thorpe is the executive director of the Partnership to Fight Chronic Disease, and we heard him speak alongside former Senate majority leader Tom Daschle and a variety of health policy experts, at the organization's symposium last week.

We've been hearing for years now about racial and ethnic disparities in health care; both The New York Times and the AP reported this week that black diabetics, for instance, are far more likely to have a leg amputated than a white with the same disease, or that a black woman is less likely to get a mammogram than her white counterpart.

But evidence has mounted that disparities are not just racial, cultural, or even socioeconomic. They are also regional, or geographic. Some parts of the country practice a far more intensive form of medicine than others—sometimes doing too much more, running up procedures and costs and inpatient bills and specialty consults without any true health benefits. And sometimes they do too little; millions of people do not get the proven benefits of primary and preventive care and screening.

Another reminder that with health policy, we often know less than we think we know. And that even when things like job-based wellness programs make sense intuitively, the supporting evidence might not materialize as quickly as we'd like —or work out exactly as we hope when we hope it.

Health and Wellness Initiatives: The Shift from Managing Illness to Promoting Health, released this week by the Center for Studying Health System Change, found that health plan initiatives to promote workers' health and wellness are now common—partly because of the mounting concern about U.S. obesity rates. But we don't yet know whether the investment is paying off —or for whom.

Thanks to improvements in public health, biomedical research, and sanitation we live longer than earlier generations. But we also die longer. And neither our medical system nor our attitudes have caught up with that reality. As one geriatrician once told me, "We still think we'll wake up dead one day."

Dr. Joanne Lynn, a geriatrician, researcher, author. and at times Really Indignant Person, has been one of the most influential voices in trying to get the U.S. health care system to adapt to the needs of patients with chronic diseases, aging, frailty, and the years of slow decline and increasing disability that often precedes death.

"We are all old people in training," she likes to say. "Where is the care system?"

We heard Dr. Lynn address a recent briefing sponsored by the Hastings Center as part of its bioethics agenda for 2008. (Dr. Lynn is now working at the Centers for Medicare and Medicaid Services, but asked that we stress that she was speaking for herself, not as a CMS employee. Although knowing Dr. Lynn somewhat, we strongly suspect that she didn't say anything in public that she's not saying even louder in private to people who really matter).

"Patient-centered medicine" is one of the buzzwords in health these days, so it was refreshing to hear from patients who actually had a voice in finding that center. Four spoke at a panel this spring sponsored by the Institute for Healthcare Improvement. Four patients. Four very different experiences. All had some success in creating a more responsive health care system. And when we at New America talk about reforming health care, we don't just mean insuring people. We want everyone to be covered so they can be part of a system that delivers high-quality, cost-effective, patient-responsive care.

(If you are interested in the difference between "patient-centered health care" which involves how we deliver care that patients need, and "consumer-directed medicine" which is a market-oriented approach to financing health care, read this Healthbeat post. They are not necessarily mutually exclusive, but they aren't synonymous.)

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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:

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.

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.