The nation's hospitals and physicians are failing to properly care for the chronically ill, and the problem isn't going to go away anytime soon.
Stronger incentives needed to focus providers' attention on costly and common medical problems: IOM
A report from the Institute of Medicine says an epidemic of chronic illness is approaching crisis proportions, driven largely by a reimbursement system and culture that reward caregivers for treating specific illness and disease rather than tending to the broader health of a patient.
The IOM in its Jan. 31 report, Living Well with Chronic Illness: A Call for Public Action, makes 17 recommendations designed to push the healthcare system to better treat patients suffering from chronic conditions and also prevent more of them from acquiring chronic illnesses in the first place. The recommendations include changes to the healthcare reimbursement system, a possible renewed chronic-care focus on the part of the Centers for Disease Control and Prevention and improvements in the surveillance and care guidelines in the treatment of patients with at least one chronic condition. The issue has serious implications for patients and the country, as the CDC has estimated that more than 75% of healthcare costs are attributable to chronic conditions.
Part of the problem has been created by medicine's success in getting people to live longer, albeit with chronic conditions that can have a serious effect on their quality of life, said Dr. Patrick Remington, who sat on the committee that oversaw the IOM report and is associate dean for public health and professor of Population Health Sciences at the School of Medicine and Public Health, University of Wisconsin at Madison. The incidence of kidney disease is “clearly epidemic,” but is the consequence of patients living longer than they used to, Remington said.
But the other aspect to the problem is that the medical system is designed to reward people for services provided, not for patient health, he said. “The healthcare system doesn't really mind more people with more chronic disease. That's the elephant in the room,” Remington said. “That is one of the reasons why healthcare costs are skyrocketing.”
Clinicians and administrators want to provide appropriate care, but the system effectively discourages it, Remington said. “We're trying to figure out how to purchase health and not pay for disease care,” he said.
Getting over that hurdle is one of the goals of the 304-page IOM report, which suggests the CDC do things such as make greater use of new and emerging economic methods in making policy decisions that will promote living well with chronic illnesses. The IOM also recommends that federal and other payers create “new financing streams and incentives that support maintaining and disseminating emerging models that effectively address persons living well with chronic illness.” Another priority, according to the IOM, should be better access to information, and the report suggests that HHS support pilots focused on using de-identified patient-level data in aggregate at the local, state and national levels.
Hospitals could, but don't, improve the health of chronically ill patients with better coordination of care. “What hospitals should be focusing on is how to reduce fragmentation of care,” said Brian Austin, associate director for the MacColl Center for Health Care Innovation, which is part of the Group Health Research Institute in Seattle.
Patients can bounce around from hospitals to primary-care offices to specialist offices without a clear plan of care and the patient feeling unsupported by the system. Merely getting a patient to actually follow through on referrals can have a big impact in the health of the chronically ill, some hospitals have found, Austin said.
Austin noted, though, that he is optimistic that solutions to some of the problems in chronic-care management may be on the horizon. “I don't think a lot of hospitals see (chronic care) as aligned with their business practices yet,” because many chronic-care programs cost them money and don't have a financial payback, he said. Solve the reimbursement problem and hospitals and physicians will get on board, he said.
Also holding back progress is the fact that the culture and structure of care may have to change to reduce chronic illness, and patients need to take charge of their care. Often the patient needs to change his or her lifestyle and behavior, and “we know how difficult behavior change is,” Austin said.
Providers have seen success with efforts treating chronic disease, but none has been expanded so far to a truly national level. The MacColl Center played an important role in the creation of the Chronic Care Model, which was developed with the backing of the Robert Wood Johnson Foundation and has been adopted for use in various areas across the country. Paula Suter, who works in the home health and hospice division of Sutter Health, Sacramento, Calif., drew on the Chronic Care Model in her work helping to develop a home healthcare-based chronic treatment model that has resulted in the training of almost 4,000 clinicians in its methods at home health agencies in 30 states.
At the center of the model is the patient, who may have a low level of health literacy and also may not get the attention needed regarding the non-medical side of patient care, said Suter, who is director of chronic-care management at Sutter Care at Home, based in Fairfield, Calif. Suter also was one of the 73 chosen to participate in CMS' Innovation Advisors Program, which is testing new models of payment and healthcare delivery (Jan. 9).
Patients need knowledge and self-confidence to properly self-manage their chronic conditions and medical caregivers aren't usually equipped to give them that. “Clinicians, we've really been socialized to assume a role of authority. We're very directive. When you're dealing with a patient with a chronic condition, that doesn't always work,” Suter said.
Caregivers can be more of a collaborator when it comes to the treatment of chronic conditions, she said.
Collaboration also is an important part of Project ECHO, a chronic condition-focused program created through the University of New Mexico School of Medicine that uses telehealth methods to provide specialized treatment in underserved areas. That project also had support from Robert Wood Johnson.
Project ECHO, which stands for Extension for Community Healthcare Outcomes, is based on an approach in which specialists in an academic medical center train outlying primary clinicians via video in the methods of treating chronically ill patients. The project grew out of a need to treat rural residents of the state for hepatitis C, which is treatable but requires care from multiple specialists.
The project eventually led to the creation if 21 centers of excellence for treating hepatitis C in the state, and the model is being adopted by several other medical centers across the country for other chronic conditions, said Dr. Sanjeev Arora, director of Project ECHO and a professor of internal medicine at the University of New Mexico Health Sciences Center, Albuquerque.
The CMS also has demonstration projects devoted to chronic care in the works, many of which are a part of the Patient Protection and Affordable Care Act. One of the latest is the Independence at Home Demonstration, a program to encourage better coordination of care through home-based primary care that was announced in December.
Chronic care plays a big role in other ACA projects, such as those intended to nurture accountable care organizations and medical homes. But one industry expert argued that the country needs fewer demos and instead should implement existing proven models nationally. “There are things we could be doing and aren't,” said Kenneth Thorpe, executive director of the Partnership to Fight Chronic Disease and a professor in the Rollins School of Public Health at Emory University, Atlanta.
For example, Thorpe said the existing federal Diabetes Prevention Program should be expanded nationally, in part using the approach adopted by the YMCA of the USA in YMCAs across the country.
An expansion of that program nationally would cost about $80 million and would provide access to diabetes prevention treatments and approaches for 50 million of the estimated
57 million adults who have prediabetes, according to an article Thorpe wrote in January's Health Affairs. “We have the tools in front of us.”
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