Chronic Disease

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.

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.

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."

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.