Saturday, July 26, 2008

Is an Entirely New Model of Care Needed for Chronic Conditions?

There was a very interesting conversation last month at New Talk, in which national healthcare leaders from across the country discussed whether an entirely new model of care is needed for managing chronic health problems. It was summarized this way:

Why overhaul chronic care delivery? For starters, about 75% of health care spending goes toward chronic conditions, and our panelists agreed that the current system is plagued by waste and poor quality.

What can America do about it? Panelists suggested eliminating one primary villain-the fee-for-service approach-in favor of the medical home or other new models that offer coordinated care and continuity of providers. This new paradigm opens the door to a patient-provider relationship marked by a two-way sense of responsibility.

Everyone recognized the potential barriers to implementation: …[including] a "multi-stakeholder approach" as an antidote to the stifling influence of interest groups; [and] regulatory waivers … essential to clearing the way for innovation.

Other challenges brought to the table include: creating incentives for engaging patients in their own health, developing a nationwide system of health care IT, and insuring that new programs dovetail into the larger system of acute and preventative care.

Other tactics proposed by the participants include:

  • Rewarding providers for delivering high quality care with minimal waste
  • Making tough choices about reducing spending on end-of-life care
  • Promoting the use of electronic health records
  • Establishing a national center for effectiveness research
  • Focusing on improving population health
  • Getting patients more involved in managing their own health, including focusing on prevention
  • Providing some form of case management.

While their recommendations are consistent with the Wellness-Plus Solution presented on our Wellness Wiki, several key elements were missing, including the promotion of:

  • Personalized care [see this link]
  • Next generation Personal Health Records [see this link]
  • Home care and Telemedicine [see this link]
  • Diagnostic decision support systems [see this link]
  • Research and delivery of cost-effective complementary and alternative care [see this link]
  • Biopsychosocial healthcare that focuses on the whole person and the mind-body interaction [see this link]

I applaud conversations like this because they bring to light how bad our current healthcare system is and how much has to be done to fix it. Yes, we do need radical reform and it's good to hear people talking about it!


Anonymous said...

I'm a career federal government employee and I know that depending on the Federal government to fix the National Healthcare System is a non-starter. I've never been in the medical profession but I'm a Technoprogressive and a Futurist and I believe that by bringing to bear a LOT of advanced IT, and other medical technologies towards these issues we have a shot at creating a cost-effective and efficacious National Healthcare System with universal access. The model I have in mind involves combining pushing the vast majority of primary care down into the "Home Care" environment. I feel that by employing Telemedicine technology in the home, combined with Personal Electronic Medical Records, that'll enable & empower the average healthcare consumer to monitor their own health and to manage injuries, chronic diseases and comply with healthy behavioral, dietary and lifestyle changes in a more cooperative manner. By taking advantage of the amount of households in this nation have PC's and Internet access, the average household can access a vast array of healthcare related information and websites with all sorts of tools and plans and management protocols that can be easily modified for individual households, and families. Care plans for individual persons within a household can be implemented and compliance can be monitored through numerous telemedicine peripheral devices. Telemedicine can allow individuals to monitor their own health in the privacy in their own homes and also provide their clinicians with a surveillance capability so that they can keep an eye on their patients health (subject to their patience compliance with the reporting protocol). I feel that instead of all of the classical solutions that are currently being offered, that what's needed is to reengineer the entire infrastructure so that all care except various types of intensive care, trauma & surgeries that can't be performed on an outpatient basis are pushed out into the community on a much more extensive basis than they are currently. The model that I've been developing envisions care being rendered in an inverted pyramid with telemedicine in the home at the bottom, at the next highest level of care would involve receiving a homecare visit from a trained caregiver, at the next highest level of care would be referrals to outpatient clinics, express clinics in Malls (or big box retailers like Walmart or Kmart) or MRI/CT centers, Ambulatory SurgiCenters/Day SurgiCenters or specialty care clinics and at the highest level of abstraction within the health care system, care would be rendered in hospitals that render services only in an intensive, acute care setting. Hospitals would also host the central telemedicine control centers from which primary care would be rendered remotely direct into the homes of patients. All other care would be rendered at a lower (but appropriate) level of abstraction within the healthcare system. In this way, a great deal of the physical infrastructure (and its associated costs) that currently constitutes our national healthcare system can be disintermediated. In addition, all of the clinics and SurgiCenters, and the hospitals can be networked on high-speed backbone that can also support the telemedicine system so that vast amounts of data and images can be shared effortlessly. Rendering as much Primary care in the home as is practicable thru the use of telemedicine combined with homecare visits will facilitate the implementation of preventative healthcare protocols & comprehensive chronic disease management protocols. The way I see it, if you can push the "healthcare system" down into individuals homes, and use it to promote healthier, wellness lifestyles with a preventative theme, then that should lesson the necessity of so many ER visits & re-hospitalizations or the (load) that is placed on the healthcare system. If the load is lessened, then that should provide opportunities for disintermediating brick & mortar healthcare infrastructure.

Charles M. Brown
Alternative Dispute Resolution Unit
Equal Employment Opportunity Commission
500 West Madison Street, Suite 2039
Chicago, IL 60661
(312) 353-6180
(312) 353-6676

Dr. Steve Beller said...

Thank you for your comment, Charles.

Your visionary ideas show great wisdom and could actually be incorporated into the Medical Home model (i.e., a convergence of Home Care and telemedicine of which you write, and the Medical Home that is gaining increasing attention).

Although I've written about home care and telemedicine in our Wellness Wiki, I failed to add it to the bullets in the original post, which I will do now.


Anonymous said...

On the economic incentive front: Here is yet another plea for reworking the skewed health care financing system so that primary and preventive care are reimbursed at a much higher level. Some research has shown that folks internalize the prevention messages heard from their primary care providers much more than they do similar messages coming from the disease management contractors of their HMOs. PCPs need more time with patients, so that they are able to parcel out more advice about basic lifestyle issues, in order for us -- as a society -- to have a shot at population-level behavior change that may improve our chronic disease profile.

Another aspect of the economic disincentive to promote healthy lifestyles and behaviors: churn in health insurers' subscribers. In other words, health insurers have a disincentive to spend money to make subscribers healthier since they have reason to expect that the economic benefit of that investment will only be realized years in the future -- and likely by a different insurer. One solution to that issue (short of moving to a single payor system) would be to require a major shift in rate-setting methodologies and mandated benefits.

To Jack Wennberg's point that "we all die of something" -- a separate, but closely related issue is the discussion that we are unwilling to have in this country: how much health care is too much? We insist that we would never ration health care, yet there all sorts of silent rationing schemes already in place. It would be healthier (psychologically, I think) to make the rationing choices explicit, and to reduce the incredible cost burden on the system associated with end-of-life care. A recent study showed that prevention leads to greater longevity which leads to greater health care costs (simply as a function of more years lived, not necessarily more expensive care). I don't begrudge anyone reasonable health care coverage in any year of life; I am, however, concerned about the system as it stands today which delivers a tremendous amount of expensive care at the end of life.

To sum up, I'd like to see greater investment in primary care, investment in prevention (in the health care system and as a public health initiative that focuses away from the health care system per se), and an honest and open national discussion about optimal utilization of scare health care resources (including the end-of-life discussion). Taken together, these can take a big bite out of chronic health care costs. In parallel, we can discuss managing the costs that remain: for example, through evidence-based medicine, and clinical pathways informed by EBM, as mentioned by some of the panelists.

Dr. Steve Beller said...

The three strategies you discussed are excellent:

(1) Greater investment in primary care. I’d focus specifically on employing economic models that promote Patient-Centered Medical Homes, which I first wrote about 2 ½ years ago at this link and which has recently been getting a lot of press, e.g., see this link and this link.

(2) Greater investment in prevention. Yes, living longer may increase total healthcare expenditures. But such increase may actually be offset by decreased utilization since prevention means people will likely be healthier longer and may die with fewer expensive-to-treat long-term chronic conditions.

(3) An honest discussion about managing resources. In addition to making reasonable decision about rationing/end-of-life care, I’d add eliminating waste/inefficiency, as well as gaining the knowledge and having incentives to deliver only the care that is needed and to render only the most cost-effective care options, neither of which we know how to do at this time.

All these things are essential--along with EMB and health information technology (especially next-generation knowledge-building and decision-support tools)--because they are part of a grand strategy that increase value to the consumer/patient, which, I contend, is the ultimate objective.