Chronic Disease

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.

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.

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 Issues:

• Chronic Disease
• Health Reform
• Health Politics
• Health IT
• Health Insurance

We know that the record on chronic disease management programs is mixed. We need to learn from our disappointments and build on our successes.

For the cynics out there who don't believe you can cut costs while improving care: here's more evidence that you're wrong. A Chicago-area pilot project lowered costs of care for diabetics—while improving their health.

First, the program saved money by taking the counterintuitive step of lowering or eliminating co-pays for diabetes patients. Though that increased upfront costs, it ensured that diabetics didn't skimp on needed care, which helped keep them out of the hospital and the E.R.

Second, the pilot borrowed the concept of the medical home. Instead of using a physician or nurse practitioner to coordinate care and work with the patient, the pilot used pharmacists. The pharmacists were trained to give diabetics advice not only on medication, but on exercise, lifestyle, and weight management. Not a traditional role for pharmacists, but it worked. Patients trusted pharmacists and took their advice.

Republican music to our ears: "Will health reform require an upfront investment? Yes. But will that investment pay off in the long-term? Yes it will."

Teenagers. They grow up fast—pretty soon they're starting to drive, applying for college, and, according to a recent study, not getting the preventative care they need. And if we're serious about a health care system that promotes wellness, prevention and a long-term effort to bring down rising rates of chronic disease, the teen years are a good place to start.(Not to mention that it might help their parents' blood pressure.)

Using data from the Medical Expenditure Survey, researchers at the University of California, San Francisco determined that only 38 percent of adolescents age 10 to 17 had a preventative health care visit in the past year. UCSF researchers also found that most teens weren't getting counseled on important health issues such as dental care, healthy diet, regular exercise, wearing a seat belt or bicycle helmet, and the dangers of secondhand smoke. Only 10 percent of teens discussed all of these issues with their doctor, and less than half discussed any of these issues with their doctor.

Listen to anyone caring for an elderly, frail, or chronically ill family member, and you'll hear a litany of worries. They'll tell you about medical specialists who don't coordinate with one another. Patients who are sent home from the hospital or rehab without adequate information about follow up care and complex medication regimes. Delays in getting patients the care they need when they need it.

The outlook is bleak for people suffering from chronic disease, according to a recently-released survey. More and more people suffer from chronic illnesses, and they are not getting the care they need. And it's not getting any better in a recession.

Blood, sweat, and billions have gone toward studying whether different care delivery models can improve health outcomes of the chronically ill while holding down costs. A recent set of Medicare disease management pilot programs with these twin goals showed, at best, uneven results. As previously noted in this space, only three, including a promising one in Pennsylvania, have been extended beyond their initial periods. Even these programs did no yet reduce overall costs of care for the chronically ill. The key word in that last sentence is "yet."

We must not be fickle in funding delivery system innovation. Politicians and the general public have microscopic attention spans and wildly unrealistic expectations as to how quickly new health care programs can fulfill their promise. This is particularly problematic for innovations that deal with the management of chronic diseases. The problem is compounded when patients are poor, uninsured or underinsured and suffer from illnesses that were undertreated if they were treated at all. As detailed below, the state of California is discovering this at the outset of a major public investment in pilot programs focused on these populations.

Beyond questions of effective long-term stewardship of scarce public resources, there are real human costs to short-lived serial infatuation with new pilot programs. We nearly all believe that a real and ongoing relationship between patient and provider is paramount to quality medical care, yet we often reshuffle which federal program people qualify for and what care facilities they can access. Ideally patients should have some stability and consistency of access points, particularly within a system that can seem byzantine and impenetrable even to those who study health policy for a living.