Chronic care crisis is predicted; study could be catalyst for change
It’s fish-or-cut-bait time for disease management
The cost of treating chronic disease in America is becoming so massive and growing so quickly that it will overwhelm health care delivery systems unless insurers and providers opt for disease management instead of acute care, experts say.
Responding to findings in the landmark study, Chronic Care in America: A 21st Century Challenge,1 released late in November, these experts predict that disease management programs may soon come to dominate health care systems, and for good reasons. But the switch from acute care to preventative health programs has so far been slow, hampered by a lack of research and insurers that balk at paying for wellness programs.
The new study shows that 99 million Americans are living with chronic conditions but that this number will grow to 150 million in just barely 30 years. Of these, half are limited in their daily activities by their conditions, according to the study prepared by The Institute for Health and Aging at University of California in San Francisco, for the Robert Wood Johnson Foundation in Princeton, NJ.
Patients with chronic illness account for almost 70% of all hospital admissions, and their average length of stay is almost twice that of patients without chronic conditions. Annual health care costs average $3,074 for patients with chronic conditions, almost four times that for other patients. Direct medical costs for treating chronic disease is now $475 billion a year, and that cost is projected to double by the year 2050.
Many agree that health care systems, already under fire to cut costs and improve quality, must drastically change the way they do business to have a chance of coping with this looming crisis. "Disease management programs are what we need to be shooting for," says Catherine Hoffman, ScD, senior policy analyst at the Kaiser Family Foundation in Menlo Park, CA, and lead author of the study. "Those are the kinds of things that are going to allow people to live fully and optimally. If you sink a little money into a good, coordinated set of services to help people manage their chronic conditions, and if those programs are well-structured, you’re preventing hospitalizations. And there’s nothing more expensive than a hospitalization."
Unfortunately, research is lacking in the area of disease prevention, says Bill Whitmer, MBA, president and CEO of Health Enhancement Research Organization (HERO) in Birmingham, AL. HERO is a nonprofit research corporation that works with several large disease management providers.
"A major burning question is what is the impact of risk factor change on health care costs?" says Whitmer. A HERO-sponsored study is under way analyzing the impact of risk factors such as smoking and obesity among more than 60,000 patients nationwide who have been through health promotion programs. Whitmer says the study is also set up to measure impact on health care costs.
"We want to do predictive models that tell us what diseases are prevented when people eliminate these risk factors, and the costs that are saved," he adds. "But more importantly, what we want to know is when people have risk factors and they are maintained, here are the unnecessary diseases that [occur], and here are the unnecessary costs that have to be paid."
Whitmer says the data from that study will be available late next year and will indicate which types of health interventions are most cost-effective. Then programs can determine which areas of disease prevention practitioners should focus on.
"To a large extent, [practitioners] are having to fly by the seat of their pants with these programs," Whitmer notes. "What we want to do is take [disease prevention] to the next level and say, rather than being a generalist and going in there and shooting with a shotgun, it would be better if you could know where the greatest payoff is, both in regard to preventing diseases and reducing costs. Then you will be able to [target programs] and be far more effective."
Pediatric DM differs from adult care
One caveat to targeting disease management programs to specific conditions may be pediatrics, says James M. Perrin, MD, director of the division of pediatrics at Massachusetts General Hospital in Boston. The study found that only one in 15 children has a chronic condition. In addition, he says that there are only a handful of diseases that are common among children, such as spina bifida, leukemia, and hemophilia. He recommends that programs serving a pediatric population take several diagnoses at once and determine whether children are gaining access to appropriate preventive services.
"You can’t say we’re going to spend this month looking at spina bifida and the next month looking at hemophilia, because even a plan with 500 members will have too few children with those conditions to be able to look at them in a reasonable way," says Perrin. "We should . . . examine the way children are doing across diseases rather than being on a disease-by-disease basis. That’s one approach developing disease-management thinking, but applying it across diseases rather than for individual diseases. That’s absolutely essential to improving the care of children."
But like adults, he says studies done there on asthma indicate that acute care for the disease is far better than chronic care. "We’re much better at treating the acute event than we are at helping the family deal with the chronic prevention problems," says Perrin. "With children, the families are central to helping their kids grow up healthy. You have to target services and programs to families rather than just the child to keep up the quality of care."
Mayer B. Davidson, MD, associate director of clinical diabetes at the City of Hope National Medical Center and clinical professor of medicine at the University of California, Los Angeles School of Medicine, says disease state management efforts for diabetes often are hampered by third-party payers. For example, many third-party payers won’t reimburse for necessary aspects of diabetes care, such as blood glucose monitoring devices and dietary instruction.
"What needs to be done is to educate the patients about the basic skills to take care of themselves, and yet the payers don’t pay for that," he says. "It’s a disease where you can do a lot to prevent complications and high costs later down the road, but the system isn’t set up to take care of it."
With diabetes, the health care system is notoriously penny-wise and pound-foolish, notes Davidson. For example, he says it costs about $45,000 a year to keep a diabetic patient on dialysis once he or she has developed kidney failure as a complication of the disease. Davidson says he developed a diabetes program run by nurses at Cedars Sinai Medical Center in Los Angeles that cost roughly $600 a year per patient to prevent such complications.2
Nurses provided education and monitored patients, making referrals to dietitians, ophthalmologists, and other specialists as needed. Also, patients had regular appointments for laboratory testing and other procedures. Davidson says the program avoided acute hospitalizations for diabetes in an estimated 244 patients over four years. In 1995, it was abolished because of funding cuts.
"Our hospitalization rate [for diabetics] was one-fourth the national average and one-fourth the average in Southern California," Davidson notes.
But Dick Robson, president and chief executive officer of American Corporate Health. in Exton, PA, says he is seeing more of a focus on prevention. In addition to other services, the company provides disease management programs to managed care organizations, which include behavioral interventions such as smoking cessation and stress reduction.
"Our clients are moving more toward the disease management arenas, because they’re more definable," he says. "It’s not a shotgun approach where you try to get everybody healthy. You’re able to pinpoint issues and begin the process of addressing the lifestyle components that lead to extended use of the medical care system. They consist of programs that are quite measurable and can be evaluated over time."
Robson says many companies are beginning to see the advantages of preventive care. "In today’s marketplace, especially from the vantage point of corporations that are looking to reduce their medical insurance costs, they see these programs not as a panacea, but as something that has defined program elements that they can plug in and unplug as needed," he says.
Hoffman agrees. She says that disease management should be a continuum of care. When patients are first diagnosed with a problem or disease, they should receive intensive education to understand what it means to them in their own lives.
"But then also as time goes on and your condition changes, you can plug back into that and it can help you coordinate services you need if you’re further limited," she says. "So many rehab programs only deal with a certain amount of time after you’re discharged from the hospital, and then you’re on your own. Disease management should be an ongoing process."
References
1. Hoffman C, Rice D, Sung HY. Persons with chronic conditions: Their prevalence and cost. JAMA 1996; 276:1,473-1,479.
2. Peters AL, Davidson MB, Ossorio RC. Management of patients with diabetes by nurses with support of subspecialists. HMO Practice 1995; 9:8-13.
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