Tuesday, August 19, 2014

Chronic Disease Costs

The total medical care costs for people with chronic disease accounts for 70 percent of the nation’s health care expenditures.

George Halvorson, Chairman and CE of Kaiser Foundation Health Plan and Hospitals, Health Care Reform Now! John Wiley and Sons, 2007

When I read this comment in the New York Times:

“ In a policy change, the Obama administration is planning to pay doctors to coordinate the care of Medicare beneficiaries amid growing evidence that patients with chronic illness suffer from disjointed, fragmented care ( Robert Pear, “Medicare to Start Paying Doctors Who Coordinate Care, “ NYT, August 11),

I immediately thought of George Halvorson's work at Kaiser. George contends it takes systems thinking and systems implementation – cooperation and collaboration among physicians and health plans – to coordinate care.

In his book Health Reform Now! Halvorson cites a list of five chronic diseases that make up these costs.

1. Diabetes

2. Congestive heart failure

3. Coronary disease

4. Asthma

5. Depression

To these I would add cancer and chronic obstructive lung disease.

Halvorson notes it is not only these disease, but the co-morbidities that go with them. Chronic diseases come in clusters. Most patients have two or more of these diseases at the same time. It often takes five or six different doctors to take care of them, an even more if the patient comes down with an intervening related acute event, a myocardial infarction, a stroke, kidney failure, or gangrene requiring amputation.

These complications demand coordination, cooperation, collaboration, and unexpected costs. To minimize and rationalize these costs, Halvorson says we need to face four hard truths and to focus more on managing the chronic disease to avoid acute episodes.

These hard truths are:

One, costs are unevenly distributed 91% of the population accounts for 70% of costs).

Two , care coordination deficiencies exist (many doctors don’t communicate with other doctors).

Three, economic incentives significantly influence care (if you are not paid to coordinate care, you may not do so).

Four, systems thinking, coordinating care of chronic disease among doctors and hospitals and others may not be on the radar screen (instead we tend to concentrate on acute events, which are more dramatic and demanding of more atte4ntion.

Given these truths, CMS may be on right track when, starting in January 2015, they will pay doctors $42 for coordinating care of chronically ill Medicare patients. Unfortunately, this CMS move, like many government programs, may be subject to misinterpretation, malfunction, and abuse. It depends, for example, on doctors having electronic health records that communicate with other doctors’ electronic records. This is not yet the case in America. One doctor’s EHR may not communicate with another doctor’s EHR, and the hospital’s EHR does not talk to the multiple EHRs of its medical staff.

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