The Cost of (Not) Implementing Chronic Care Management
Photo by linda yvonne via Flickr
Health reform’s primary beneficiaries will be the uninsured, but it should also benefit those with “good” insurance. We all know horror stories of well-insured relatives and friends driven from pillar to post in attempts to get good treatment for serious chronic conditions. It too often seems that no one is in control: doctors aren’t paid to talk to patients, but rather to do things to them, and the roles of other professionals (e.g., advanced practice nurses) are sometimes minimized. As I’ve described earlier, there is some good news regarding medical practice reform in the bills, particularly for people with Medicare or Medicaid.
How do we get people into medical settings where their chronic conditions can be well-managed? Interesting work is being done in many quarters on this issue. In a recent Health Affairs paper, Steven D. Pizer and coauthors reported that people with chronic conditions in regions of the country with thin Medicaid programs are likely to be uninsured, notwithstanding Medicaid’s strong orientation toward disability and chronic care. In a companion article, Andrew P. Wilper and coauthors reported on high levels of uncontrolled — often undiagnosed — chronic conditions (hypertension, diabetes, and elevated cholesterol) among people without insurance. Public insurance expansions in pending reform bills would assist these low-income people with chronic illness get coverage, and the chronic care provisions have the capacity to provide appropriate medical management of their most pressing conditions.
Structure is emerging on best practices for the delivery of sound coordinated care. The NCQA has worked with physician groups to create tools to evaluate practice settings according to their ability to serve as therapeutic homes for all, but in particular for those with chronic conditions. The Physician Practice Connections - Patient-Centered Medical Home program provides tools for public and private payers to evaluate a physician practice before designating it a “medical home” - and compensating it accordingly. The tools evaluate prospective medical homes on factors such as their active support of patient self-management; use of non-physician staff for patient management; employment of procedures to maintain high levels of patient communication; and adoption and use of evidence-based care management protocols for chronic illness.
So how much does it cost to do this right? A recent study from Commonwealth Fund sheds some light on this complex issue. In the study, Stephen Zuckerman and coauthors take on the difficult task of examining the marginal cost of converting a 20th Century practice to a 21st Century medical home. It makes interesting reading, and tentatively suggests that the cost could be modest. Zuckerman et al. are attempting to compute cost. They recognize that cost is only a component in a more important calculation: what is the value of creating medical homes? They cite to a 2008 Deloitte report that gathers research tending to show that the cost is probably worth it, even in purely economic terms. That is, it appears that the savings achieved in avoided hospitalizations and other expensive interventions is significant, washing out the cost of supporting sound chronic care management. It is not, of course, only about efficiency; ending the chronic care horror stories is the true goal.
Expanding insurance is only the first step in delivering the care people need. For people with chronic illness, the finance and delivery system needs to work with the whole person, family, and community, and not slice the patient into 8 minute blocks and procedure codes. A consensus statement of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association describes a commendable principle of care coordination that has particular application for people with disabilities and chronic illness:
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Practice follows payment. Payment reform must facilitate the adoption of practices that serves chronic needs.
Federal funding may be encouraging a move toward EHR, but there’s more to it than just installing systems. How can healthcare data pooling lead to a better system? More at http://www.healthcaretownhall.com/?p=1499
I agree that EHR is not much use if it is not integrated into a health information exchange with broad reach. The info in a “siloed” EHR gets out of date, and can become dangerously incomplete. Many of the health information exchanges that will be funded by federal ARRA money seem to be integrated regionally or by state, and are set up to permit broader interconnection. Everyone has been frustrated by years by the lack of interoperability in health data systems; maybe that is changing. Another thing: You’re right that it isn’t just a matter of installing equipment. Personnel support has to be built into the process of getting PCPs into data exchanges in a meaningful way. A pilot in the Philadelphia area brings together public and private payers to support these efforts. Kaiser and the Center for Health Care Strategies are doing Webinar on this on Wednesday – registration info here. More information on the pilot here.