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Ex­perts call on providers to de­velop more ef­fec­tive and ef­fi­cient strate­gies to care for com­mon mal­adies

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. 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 sys- tem, 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 reim- burse­ment 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, p. 8).

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 pri- mary 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.”


Pa­tients in New Mex­ico wait to be helped at Project ECHO, a chronic con­di­tion-fo­cused pro­gram that pro­vides spe­cial­ized treat­ment in un­der­served ar­eas.

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