Reduce Healthcare Spend: Focus: Chronic Diseases

Behavior aligns with incentives. If a salesman’s pay is tied to new sales, they will seek new sales. If car mechanics are paid by the hour, they will work slowly, not rushing to get their job done quickly – pay them by the job and they will rush, perhaps too much. This rule holds in healthcare as well: Physicians, hospitals, insurance companies act according to their incentives.

The US healthcare system is diverse and poorly integrated, why? Because there is little incentive for Physicians, hospitals & insurance companies to integrate. Furthermore, our “free market system” does create market forces that push these various entities to integrate.

Though many experts realize the crisis facing our healthcare system, patients are grossly unaware.

http://www.gallup.com/poll/123149/cost-is-foremost-healthcare-issue-for-americans.aspx

Overall, 80% are satisfied with the quality of medical care available to them, including 39% who are very satisfied. Sixty-one percent are satisfied with the cost of their medical care, including 20% who are very satisfied.

http://www.realclearpolitics.com/articles/2009/08/13/the_health_care_reform_paradox__97866.html

Most Americans continue to support major reform. But multiple polls show they are also overwhelmingly satisfied with the quality of their personal medical care, as well as their insurance coverage.

US Healthcare: the cost without the value

We spend more than any other country in the world on a per capita basis.  The total Healthcare spend in the US is $2.4 trillion or $2,400,000,000,000. The graphic (Cost of a Long Life) shows the relative spend rates versus life expectancy across countries.

Though the US shows a huge cost spike, we rank low on the life expectancy list. To put it another way, spend does not correlate with an longevity outcome.

http://ucatlas.ucsc.edu/spend.php (the purple line represents spending)

Chronic Diseases (75% of costs: $1.8T of $2.8T)

Pragmatism begs focus on the largest part of the problem: of the $2.4 trillion, $1.8 trillion or 75% of the total healthcare spend is used on chronic diseases. These “frequent flier” patients suffer more, cost more and have worst outcomes than they need to. Much cost could be reduced by addressing this population.

Chronic diseases (at a glance: http://www.cdc.gov/nccdphp/publications/AAG/pdf/chronic.pdf)

CDC: http://www.cdc.gov/nccdphp/publications/AAG/chronic.htm

• Chronic diseases cause 7 in 10 deaths each year in the United States.
• About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.
• More than 75% of health care costs are due to chronic conditions.
• Approximately one-fourth of persons living with a chronic illness experience significant limitations in daily activities.
• The percentage of U.S. children and adolescents with a chronic health condition has increased from 1.8% in the 1960s to more than 7% in 2004.

 

http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=134063

Can the outcome be better? (more value for lesser cost?)

The answer seems to be a resounding YES. According to the CDC, these chronic diseases are preventable.

http://www.cdc.gov/nccdphp/publications/AAG/chronic.htm

Four common, health-damaging, but modifiable behaviors—tobacco use, insufficient physical activity, poor eating habits, and excessive alcohol use—are responsible for much of the illness, disability, and premature death related to chronic diseases.

This report by lewin.com provides a framework: http://www.lewin.com/content/publications/LewinReport-CostDrivers.pdf

Episodic care + Chronic diseases = poor outcomes

Our healthcare system focuses on episodic care via poorly coordinated care givers and institutions which results in fragmented, sub-optimal care for chronic patients.

An article published by California Healthcare Foundation highlights specific issues: http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=134063

• 33% of chronically ill patients leave a doctors office confused as to how to continue their care
• 57% said their doctors did not ask how they could manage their health at home
• Patients receive preventative care only 56% of the time (as of 2003)

In essence, the research indicates that US Healthcare takes a patchwork, episodic approach to managing chronic disease as opposed to a continual and integrated approach that seeks wellness as the outcome.

How to address chronic diseases better?

If wellness is our outcome and prevention possible, then episodic care should not be only strategy used to address chronic disease.

Improving Chronic Disease Care Organization: http://improvingchroniccare.org/

Their Model focuses on a more integrated model that extends beyond hospital / doctor visits and episodic care to a more encompassing model. The primary players being a well informed patient and integrated healthcare systems – very different from the current state of Healthcare.

What needs to be overcome / done?

http://improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

• Rushed practitioners not following established practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illnesses

Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible

Elements of the solution:

• Patient Safety (in Health System);
• Cultural competency (in Delivery System Design);
• Care coordination (in Health System and Clinical Information Systems)
• Community policies (in Community Resources and Policies); and
• Case management (in Delivery System Design).

A large body of papers & studies have findings presented on the site. [ here ] I found this one interesting:

http://www.rand.org/health/projects/icice/ccm.html

Chronic Care Model (CCM) Implementation Emphases,
Marjorie L. Pearson, Shinyi Wu, Stephen Shortell, Jill Marsteller, Peter Mendel, Michael Lin, Emmett Keeler (not yet published)

Conclusions: Of 23 change emphases, only 4 distinguished the best CCM implementers (i.e., the organization whose change activities were most likely to have impact, according to CCM principles). These key emphases included organizing and engaging practice teams, collaborative decision making with patients, encouraging provider participation in QI efforts, and de-emphasis on traditional patient education. …

To successfully implement CCM, organizations should be encouraged to emphasize practice teams, patient collaboration, and provider participation in their QI strategies and to not over emphasize traditional patient education.

Using patient participation to help manage chronic diseases.

http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=134063

Participatory Health: Online and Mobile Tools Help Chronically Ill Manage Their Care

Jane Sarasohn-Kahn, THINK-Health

Patients recorded various biometrics through out the day, such as blood pressure. An ideal system put forth in the article would contain:

1. Support for self-defined health regiments (activities).
2. Monitor patient “status”
3. Continual modification of health regiments (patients + health coaches + providers)
4. Interpret recorded data as it relates to individual treatment goals
5. Continual learning about patient health by both patient & provider
6. Continual, timely communication to patient and actionable recommendations.

Consider what sources / information patients value & trust:

What is of particular interest is the trend of traditional care givers taking on ever more important roles, i.e. making doctors more accessible is highest value.

[Contradiction]

Regardless, e-Patients (patients that look for healthcare information online) is an increasing trend.

e-Patients : A new trend to participatory healthcare

http://e-patients.net/archives/2009/10/participation-matters.html

Internet penetration:

• 79% of adult Americans have access to the internet.
• 63% of adults have broadband internet connections at home.
• 56% of adults access the internet wirelessly on some device, such as a laptop, cell phone, MP3 player, or game console.

Adoption:

• 60% of e-patients (internet users who go online for health information) have engaged in some sort of social media related to health and health care.
• 42% of all adults say they or someone they know has been helped by following medical advice or health information found on the internet.

However, while mobile adoption is creating greater access and participation among African American adults, for example, there are other groups who remain disproportionately offline, such as people living with chronic disease or disability. They may be missing out on opportunities, but just as importantly, we are missing their voices in the conversation.

The Pew Internet/Health FAQ

by Susannah Fox on November 20, 2009

This talks about the trend.   http://e-patients.net/archives/2009/11/the-pew-internethealth-faq.html

Most people’s first stop for health information is a general search site. Google dominates the search market. A British Medical Journal article found that Google is a pretty good diagnostician. Very fewpeople report bad outcomes from their online health research.

How to get patients to participate?

Health Gaming

Health games are an entertaining idea. http://www.healthgamesresearch.org/  [Twitter: http://exergaming.pbworks.com]

The idea is to use entertainment to teach. By making players keep their avatars (game actors) healthy, they learn how to keep themselves healthy.

Even social health gaming sites have begun to pop-up: http://gaming4health.com

Medication management:

Getting patients to take and complete their prescribed medications is important, difficult to enforce and a large issue in modern healthcare. According to California Healthcare Foundation:

• 60% of all patients do not comply with their prescription regiments.
  • Reasons: (per InRange )
    • Forgetfulness. Many people forget to take their medications or forget that they have already taken their medications and take them again.
    • The medication regimen is very complex. Many people take multiple medications and the instructions for taking them can be confusing. When and how one takes their medications is critical to proper treatment.
    • Medication changes. Prescriptions are discontinued, doses are changed and new prescriptions are added. It is not uncommon for a physician to stop one medication and prescribe an alternative. However, the patient may not remember to stop taking the original medication.
• 50% of patient’s do not adhere to maintenance medication regimens within 12 months.

There are solutions addressing this such as:

In)Range’s EMMA product:

Benefits of Emma: http://www.inrangesystems.com/index.php?page=benefits-of-emma

eMedMobile uses mobile phone reminders.

I couldn’t find any reviews or online posts of people using this application.

HealthHonors: point system to incentivize regimen adherence

Currently unavailable as they are building their mobile platform.

The Carrot.com helps track compliance and health activiites:

They provide a more comprehensive list of trackers that are listed here: http://thecarrot.com/index.php?m=trac&a=tracIndex&modMode=list

Partial list:

Various other Health applications:

(Crohn’s disease)

(Diabetes)

(Wellness)

(Weight loss)

How to get better outcomes

At the beginning of this blog, the point of alignment of incentives was put forth. The system has to work together and move away from incentivized episodic care. How do we get there?

California Healthcare Foundation puts forth a road map in their article.

1. Align incentives
2. Engage Clinicians
3. Clarify Regulations
4. Inspire health engagement through incentives and personalization

Align Incentives:

As this blog shows, there are an ever growing number of applications that address various healthcare issues, but payers (insurance companies) often do not cover these pro-active solutions.

Engage Clinicians:

Doctors are paid for episodic care – when patients come in and are sick. They do not get paid for health patients. Doctor engagement must be incentivized.

Clarifying Regulations:

With Healthcare reform pushing through the Senate with a 2,000+ page bill, clarifications looks murky at best, but we’ll hold out hope until a bill is passed.

Inspiring Health Engagement:

To change requires inspiration and tools that enable engagement. There are a variety of ways people are inspired to change, incentives could play a role. One idea is P4P4P, Pay-For-Performance For Patients, even paying patients a small amount can have positive outcomes.

http://www.healthpopuli.com/2009/06/p4p4p-paying-patients-to-be-healthy-and.html

• 9.4% of smokers who were offered $750 in incentives to quit smoking were able to remain smoke free for 18 months, compared with just 3.6% of smokers who tried to quit without financial incentive
• Dieters who could earn money by loosing weight lost more pounds more quickly than those who weren't offered a monetary reward
• Patients who regularly forget to take their medication and have the chance to win an average of $3 per day in a daily lottery pushes many of them to remember to take their daily doses.

Conclusion

No doubt, patient participation, more integrated providers and engaged clinicians would help reduce costs and drive better outcomes… But as the 4 part road map shows, the way is paved with hardships. Payers will need to change their payment structure & formularies, clinicians must change their behavior, regulations must be clear & aligned and patients inspired to get involved.

We have much work to do…

About hitmanalan

Alan has worked in Healthcare IT for the past 9 years at the following companies: http://www.medco.com/, http://www.merck.com/, http://www.ammeddirect.com/.