Chronically ill are going without care: What will be the impact on Medicaid?
Of 20 million working-age adults with chronic conditions and medical bill problems, half delayed care in 2007, and 56% didn't fill a drug prescription. More than 5 million of this group went without needed care altogether.
In addition, 39% of the working-age population, or 72 million people, had at least one chronic health condition, such as diabetes, asthma, or depression in 2007. This is a significant increase from 35% in 2003 and 34% in 2001.
These data come from a May 2009 report, Financial and Health Burdens of Chronic Conditions Grow, from the Center for Studying Health System Change in Washington, DC. The report shows that a significant number of Americans with chronic conditions are going without care due to problems with medical bills.
"The article and study point out the major crises we are facing in health care," says Robert A. Crittenden, MD, MPH, professor at the University of Washington School of Medicine in Seattle.
Dr. Crittenden is referring to the economic trends of employers providing health benefits for fewer people, insurance practices that systematically reward avoiding sick people, and declining health status for many people caused by problems such as obesity.
"For the first time in generations, we have a train wreck developing in front of our eyes. Worsening health for many people is being exacerbated by gaps in our economic and regulatory systems," he reports. "We can either all share in this problem; or we can, as we usually do, leave those friends and neighbors to find their way in a very poor system."
Too little, too late?
Dr. Crittenden notes that most people do not have the economic capacity to overcome the failures of insurers and the employer-based system. As a result, many people are not taking the medications they need, and increasing numbers are facing bankruptcy.
"Many will be sick and poor enough to qualify for Medicaid at a time when Medicaid cannot contend with a big increase in caseload," Dr. Crittenden predicts. "The systems are not there to care for these people. We could do better."
As for disease management, he says stand-alone, vendor-provided chronic disease management solutions may "get minimal savings but do little overall. Most people with chronic diseases have more than one disease and need a more integrated approach," Dr. Crittenden says.
A primary care-based, coordinated care system was recently piloted by Group Health of Puget Sound. "They have found improved outcomes, more satisfied patients and providers, and a break-even cost," reports Dr. Crittenden. "My read from that and other models is that we can do better and improve outcomes if we integrate and not divide care, using the plethora of skills available. Using specialists only, or primary care only, are both less effective than a team approach."
The bottom line, though, is that if people do not have insurance, they are unable to manage chronic illnesses, which is necessary to improve their health and control rising health care costs. "Unless we have significant reform that either changes the exclusionary policies of health insurers or causes an increase, and not the expected decrease, in employer-based insurance, this will not occur," he says.
Dr. Crittenden notes that the evidence shows that what's needed is to change the way care is delivered, involving the patient, the physician, and the rest of the team, instead of doing a "partial fix."
"When people do get sick or poor enough, we offer them an overburdened Medicaid," he explains. "This is good and helpful, but the backstop comes into effect only after people are sick enough to be disabled from work or completely broke due to a very high pile of bills. At that point, chronic care management is late for the people affected."
Burden falls on Medicaid
Newly unemployed and uninsured individuals face tough choices regarding their personal finances. "Unfortunately, many individuals will forego or delay treatment and/or drug therapy for chronic conditions in an effort to make ends meet," says Tammy Murray, JD, MBA, RN, a principal of Lansing, MI-based Health Management Associates. Ms. Murray is based in Indianapolis.
"Inevitably, state Medicaid programs will experience increased enrollment of individuals with chronic conditions that are not well controlled because they forwent or delayed treatment before seeking public assistance," says Ms. Murray.
People with uncontrolled chronic disease may first access the health care system through otherwise preventable hospitalization, increasing the financial burden on state Medicaid programs.
For many providers who treat chronic disease, Medicaid is a small revenue stream because of low reimbursement methodologies. "Physician manpower shortages and adverse selection of Medicaid populations have already created substantial access issues. This encourages Medicaid beneficiaries with chronic disease to seek more expensive care through hospital emergency departments," says Ms. Murray. "This problem is likely to grow."
Care management on the rise
In Washington State, there has been a dramatic increase in people applying for Medicaid benefits at the local community service offices, as well as a steeper than forecasted increase in eligible clients. "This has a ripple effect of increased costs in an already difficult budget time," says Shirley Munkberg, acting office chief of the Health and Recovery Services Administration's Office of Quality and Care Management in Olympia. "The reality is that there is increased need for services and decreased money available."
The budget deficits in state funds make it very important to use care management best practices in a "focused, targeted way," she says.
One current initiative in Washington involves identifying Medicaid clients who are frequent ED users and/or have co-occurring disorders, such as chronic mental illness or substance abuse, through a sophisticated software application. "The application has tested capabilities to predict future health care costs and utilization patterns," says Ms. Munkberg.
In addition, the state has implemented several chronic care management programs targeting the highest-needs clients. These include individuals with complex physical conditions, and those with co-occurring mental and substance abuse disorders, in both fee-for-service and managed care.
A recent randomized, controlled study on chronic care in Washington showed that the state was budget-neutral over the short term, but that mortality was reduced. "Based on that, we can hope that chronic care management is changing the disease trajectory somewhat and that the cost savings will follow over time," says Ms. Munkberg.
According to Gregory Vachon, MD, MPH, a principal of Health Management Associates, the rising numbers of uninsured working-age people with chronic disease is "sure to sharpen the focus on disease management efforts in Medicaid."
Dr. Vachon says these three questions must be answered, however:
Are traditional disease management approaches, in fact, effective?
Are they cost-effective beyond congestive heart failure?
Are there other models of chronic disease management that could potentially replace the currently labor-intensive disease management models?
Although traditional chronic disease management programs may be effective, they are quite expensive. Ms. Murray says as enrollment increases, this may be an opportune time for Medicaid programs to consider new, innovative approaches to encourage less expensive self-management of chronic disease.
"Although some states have had their budget crises temporarily relieved with stimulus money, long-term, affordable chronic disease management strategies are imperative if states are to provide health care financing for more and more people," she explains.
With the potential for higher enrollment of individuals with poorly controlled chronic disease, Medicaid programs will be forced to lower the cost of this care, decrease benefits, or set higher eligibility standards. "These tough decisions will require innovative solutions," Ms. Murray points out.
Routine chronic condition assessment and care can be delivered at a lower cost and in a more efficient and convenient setting, she argues. She says retail clinics staffed with nonphysician providers, enrollment personnel, and community resource workers are viable options.
"Generally, nonphysician practitioners with prescribing authority can deliver routine chronic care within their state scope of practice," says Ms. Murray. "In some states, however, reimbursement methodologies prevent such practices. This should be re-examined, given the primary care physician shortages and increased prevalence of chronic disease."
The use of nonphysician health care providers such as nurses, physician assistants, and pharmacists could potentially improve access, convenience, and patient compliance. "Still, a collaborative physician network is imperative to this innovative approach to chronic condition management," she contends.
Ms. Murray says individuals should be encouraged to self-manage their chronic conditions, working with care teams that deliver the right care, at the right time, and in the right setting.
"State Medicaid programs should look at incenting patients for effective self-management of their conditions, through decreased copays for supplies or medications or other incentive schemes," she says. "In some instances, regulatory barriers may need to be addressed to achieve this goal."
Although Ms. Murray believes that a less expensive approach to chronic disease management, such as retail clinic models for routine management, will be needed as more and more individuals with chronic disease apply for public programs, a coordinated team approach with primary care physicians at the core is important.
"Several states have looked at or implemented innovative approaches to chronic disease management, including self-management. Some are looking at patient incentives," she reports. "In some states, the managed care organizations developed disease management programs to improve beneficiary compliance and outcomes."
One problem, says Ms. Murray, is that those programs generally cost money in the short-term with the promise of long-term savings, depending on Medicaid recipient tenure. "Given the financial situation of most states, it can be very difficult to propose more spending," she says. "The system we have today is due, in part, to this short-term perspective."
Dr. Vachon says he believes that if patients are offered incentives to keep their chronic diseases in good control, they will then use community resources, including web-based support, to attain those incentives.
"Control assessment and medication adjustments will occur in more efficient settings than the doctor's office," he explains. "Look to the retail pharmacies, clinics, and other innovative models to deliver this routine chronic disease care. We are in for more change. And well we should be."
Contact Dr. Crittenden at (206) 744-9192 or [email protected], Ms. Munkberg at (360)725-1648 or [email protected], Ms. Murray at (317) 575-4011 or [email protected], and Dr. Vachon at (312) 641-5007 or [email protected].
Of 20 million working-age adults with chronic conditions and medical bill problems, half delayed care in 2007, and 56% didn't fill a drug prescription. More than 5 million of this group went without needed care altogether.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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