Timothy S. Jost Robert L. Willett Family Professorship of Law Washington and Lee University School of Law

Posted June 24, 2008, 10:02am

It is perhaps not surprising that we spend so much on chronic care, as care for chronic illness assists 133 million Americans to lead more productive and satisfying lives. Much of the value of our health care system is found here. Intuitively, however, it would seem that our balkanized fee-for-procedure-based health care system would not provide optimal care for chronic illness. Better coordination of care seems an obvious solution. Both presidential candidates seem to believe this to be true. But what works better? Medicare chronic care-oriented demonstration projects, to date, have failed to demonstrate dramatic cost-savings and only marginal patient care improvement. Also, most Americans are privately insured. If we knew how to deliver chronic care more effectively, how would we change private insurance payment to encourage it? Mandates? Tax incentives? And what are the levers to change individual behavior? Cost-sharing? The evidence shows higher cost-sharing reduces rather than improves compliance.

Peggy O Kane President National Committee for Quality Assurance

Posted June 24, 2008, 10:20am

Do we need a new model? We actually have a number of models to manage chronic illness.

—Disease Management—developed by "accountable health plans," and now also deployed by independent vendors who contract with plans, employers and the public sector. Performance of plans is widely reported and results have improved dramatically over time for many chronic illnesses, but this is largely on HMO plans to date. There are notable exceptions, for example CIGNA and Aetna are now reporting on their PPOs as well, and Medicare and the Federal Office of Personnel Management require PPO reporting.

—Physician-level recognition programs and reporting initiatives, often coupled with pay-for-performance.

—Medicare group practice demonstration—heavily focused on chronic illness, with gain-sharing to reward efficient, high-quality care.

There is good evidence that all these approaches improve quality, the problem is deployment has not been broad enough. The issues with health plan accountability are mentioned above. With the delivery system level, implementation has been even less broad, often focused on large med groups that are prevalent in only a few geographic areas.

John E. Wennberg Founder and Director Emeritus The Dartmouth Institute for Health Policy and Clinical Practice

Posted June 24, 2008, 10:26am

While death from chronic illness might be pushed back in time by better prevention or tighter management of, say, diabetes, progression to death from one or more chronic illnesses is the fate most Americans inevitably face; most of Medicare's dollars go for managing really sick patients that are approaching this point. In the absence of some radical change in either technology or ethics, this can't be changed without reform of the way care is managed toward the end of life, no matter what the specific chronic illness. Thus, how to manage really sick patients needs to be a focus for reform. The evidence today is that in most parts of the country we have way over-invested in the acute care hospital sector because the major resource for managing patients with chronic disease-costs are higher, while outcomes are worse.

How is the nation going to address the need to reduce overuse of acute care hospitals?

Peggy O Kane President National Committee for Quality Assurance

Posted June 24, 2008, 10:30am

I have previously mentioned that there is little doubt that various models focused at the health plan, purchaser, and provider level have all shown success in improving quality. The record on cost containment is less clear.

The Medicare Health Support demonstration, focused on disease management for elders with diabetes and congestive heart failure, did improve quality, but it was terminated for failure to demonstrate savings. (Others can explain some of the reasons for this.)

Since we have good evidence from Wennberg's work that there is supplier-induced demand, it is not obvious that there will be reduction of demand accompanying more effective management of chronic disease.

Troy Brennan Senior Vice President and Chief Medical Officer Aetna Inc.

Posted June 24, 2008, 10:48am

I agree with Peggy O'Kane and Tim Jost. However, I think it is important to note that there are incentives to address the quality and costs of chronic care today. Certainly health plans have those incentives for their fully insured customers, and so do self-insured employers. As well the federal government in the Medicare program and the states in Medicaid face the same challenges. Yet for all the reasons suggested by others, their efforts in this regard have been stunted.

That is beginning to change, as a result of several factors. First the cost of care continues to rise, and it is increasingly clear this is due in large part to the costs of chronic care. Second, it is clear from years of health services research that costs can be reduced by improving quality of care—estimates range from 20-40% of today's care is waste in the form of errors, re-work, or ineffective care. Third, the promise of information technology is finally becoming clear in terms of programs that can overcome some of the miscommunication and lack of continuity that characterize today's health care system.

Now is the time to demonstrate these programs can make a difference, and many companies, large and small, are taking advantage of quite innovative ideas to do so. So we do hold out some hope that the market incentives represented by this burden of illness can call forth interesting and timely solutions.

Philip Howard Founder and Chair Common Good

Posted June 24, 2008, 11:22am

My question is this: Is there a model for chronic care that has been demonstrated to be more cost effective? E.g., a "health care home" that actively monitors and engages patients.  Or is the dramatic differential in cost between the European and U.S. systems as straightforward as the amount of resources poured into our last days, as Jack Wennberg suggests?

Timothy S. Jost Robert L. Willett Family Professorship of Law Washington and Lee University School of Law

Posted June 24, 2008, 11:45am

Medicare is working on a medical home demonstration project mandated by 2006 legislation. North Carolina's Medicaid program has had a medical home project underway for some time with reported success, and some programs in the private sector also seem to be succeeding. Again, the idea is intuitively obvious, and should be explored.
I know of no evidence that cost differences between the U.S. and Europe are primarily attributable to differences in end-of-life care. There are differences from country to country (as there are within the U.S.), and some countries probably treat terminal conditions less aggressively. The primary explanations for differences in cost lie elsewhere, however. Differences in prices is a major explanatory factor, as is less reliance on expensive technology.

John E. Wennberg Founder and Director Emeritus The Dartmouth Institute for Health Policy and Clinical Practice

Posted June 24, 2008, 12:18pm

Philip Howard asks about models for chronic care. Brent James should chime in because Intermountain Healthcare has done more than any other place I know of to rationalize the clinical pathways for managing chronic illness--for example, the relationships and roles of specialists versus generalist in managing diabetes over time. Mayo Clinic is beginning to work on the same issues, but we need a lot more focus on this aspect of the “comparative effectiveness” agenda before we can even begin to talk about cost-effective management of chronically ill populations. In the meantime, how do we control excess capacity and the damage it appears to be doing to the Medicare budget and the lives of patients??

Peggy O Kane President National Committee for Quality Assurance

Posted June 24, 2008, 12:22pm

It’s also worth mentioning that there’s a model of care for chronic conditions that has been so widely accepted in the health care system that it’s simply referred to as the Chronic Care Model. It was developed by Dr. Ed Wagner of the MacColl Institute. The model clearly defines a system for chronic illness management: patients are placed in charge of managing their health with the support of an interdisciplinary care team, decision support and clinical information tools, and resources in the community.

The principles of the Chronic Care Model – promoting evidence-based decision making, using clinical information to proactively manage care, and recognizing that a lot of health care happens outside the clinical setting – also resonates with other models of care such as the Patient-Centered Medical Home.

Although the CCM is the gold standard in terms of a model for managing chronic illness, it’s far from universally implemented. Why not? Several on the panel have had experience implementing the model, as either a clinician or a payer. I’d be curious to hear their thoughts on this.

John Rother Group Executive Officer of Policy and Strategy AARP

Posted June 24, 2008, 12:59pm

I agree with Peggy that the Ed Wagner chronic care model is widely accepted, but it's not widely implemented. Another important element of the model is patient and family engagement, supported by nurse calls and patient support groups. After all, behavior change is one of the most difficult elements of chronic care management.

Patient engagement may be one of the critical missing elements in most medical care today. I'd be interested in successful examples of programs that have managed to achieve behavioral change among those with chronic diagnoses or those at risk.

All of this points to the need to change reimbursement incentives and flexibility. Without such change, I wonder whether it's possible to truly reorient our medical system from one based on acute episodes to one that can coordinate and manage chronic conditions.

Bruce Vladeck Executive Director Ernst & Young's Health Sciences Advisory Services

Posted June 24, 2008, 1:22pm

One reason the Chronic Care Model (CCM) is not more widely implemented is because it puts central responsibility on the person who is often least capable of exercising it - the patient. Only in America would we seek to improve the quality of the health care system by transferring responsibility from the well to the sick!

I also agree with Tim J. that it’s very important to be careful in our discussions about costs, and to not confuse utilization with prices. We do spend an awful lot of money on terminally ill people, but to me that's more rational than spending health insurance dollars on healthy people (aka Medicare Advantage premiums). Far more importantly, it's not clear that optimal end-of-life care is that much cheaper; it just looks cheaper because we transfer so much of the cost to informal caregivers we don't pay, and to familial incomes and assets.

Arnold Relman Professor Emeritus of Medicine and of Social Medicine Harvard Medical School

Posted June 24, 2008, 1:28pm

Although the comments of my colleagues on this panel are well taken, I am dubious about the value of discussing how best to deliver chronic care without also discussing the whole health care system. It may be possible to separate chronic from acute care in accounting for expenditures, but in reality acute and chronic care are often required by the same patient, sometimes together, sometimes in sequence. Chronic illnesses often are punctuated by acute episodes of the same or different illnesses, and acute episodes of illness often lead to chronic, sustained problems. Therefore, in terms of the care needed by patients, the acute-chronic distinction is more theoretical than real. Yes, there are clearly institutions—both in-patient and ambulatory—that deal mainly or entirely with chronic care, but that care should be part of a system that meets all the medical needs of patients in an integrated way.

To develop such a system we will need major reform of the funding, insuring and delivery of medical care. The present inefficient jumble of competing private insurance plans and the fragmented fee-for-service delivery of medical care will ultimately have to be replaced by something more efficient, less fragmented and less driven by profit incentives. Good medical care, both acute and chronic, cannot be provided by a business-driven market, because it is in essence an essential personal service that enlightened societies owe their citizens.

Nancy Johnson Senior Public Policy Advisor Baker Donelson

Posted June 24, 2008, 1:45pm

Dr. Wagner's model and others developed by integrated care systems are making tremendous progress. But we know a lot less about care coordination in fee-for-service medicine. Some of the demos have taught us a lot about what does and does not work, as have some of the group practice demos. The difference between clinical care coordination and the chronic care support systems necessary to achieve the care improvement and cost savings possible is also becoming clearer. I think we need to understand these differences, focus greater attention on how to get patients actively involved, and promote a variety of solutions to be able to create a delivery system that can both prevent and minimize the medical and cost consequences of chronic illness, and support patients through better informed and more rational end of life decision making.

I see the challenge as creating a new health care delivery system that is as capable of delivering preventive health and care management as treatment. The chronic care demos, medical home demo and gain sharing demo are all pieces of finding our way to integrate fee-for-service systems ... as are bundling and other such payment proposals, which of course have to be integrated with quality performance requirements.

John Rother Group Executive Officer of Policy and Strategy AARP

Posted June 24, 2008, 2:00pm

It seems impossible to talk about chronic care without focusing on physician payment reforms. I agree such reforms are needed, as Nancy Johnson outlines, but it seems to me that they are necessary but not sufficient. In a truly patient-focused delivery system, we would also need decision support and counseling for patients and their families, as well as informal group supports.

Dr. Relman makes the excellent observation that it's not really possible to separate chronic care from acute care. Isn't the key point the need to move away from a specialist-centered delivery system to a patient-centered one? The role of primary care is critical to accomplishing this, and perhaps the medical home idea is a more achievable transition to this goal.

David B. Kendall Senior Fellow for Health Policy Progressive Policy Institute

Posted June 24, 2008, 2:13pm

Please let me summarize the discussion so far. Most of you support pushing implementation of a new model for chronic care delivery with three notable exceptions. Jack Wennberg says there's more inefficiency at the end of life than in the care for chronic diseases generally. Bruce Vladeck suggests that high prices in the U.S. health care system and payments to private health plans in the Medicare Advantage program are better targets for savings. And Arnold Relman says that for-profit health care is the real obstacle to reform regardless of whether it is acute or chronic care. But even if there's more potential elsewhere, should improving health care for people with chronic diseases be at least one of the goals of reform given that they are treated so poorly by the current system? If you agree, please tell us what the public and/or private sectors should be doing.

Nancy Johnson Senior Public Policy Advisor Baker Donelson

Posted June 24, 2008, 2:20pm

I think it is important to remember that all the advances in developing care management models have come from the business-driven market, not from government-run health care plans because the silo payment structure of Medicare and Medicaid prevents such developments. Interesting that the Community Health Centers with their very different payment system have been leaders in Electronic Health Records (EHR) adoption, preventative care support systems, and outreach. A home care provider I am acquainted with provides a post-episode care package that is saving people from E.R. and hospital readmissions. I think our goal is to require private systems to compete on quality, efficiency, and outcomes and, using health IT, to enable government and other entities to do the appropriate oversight to assure that individuals are getting the care they need. It is all so possible now.

I would add that without an interoperable, secure health IT (information technology) system, capable of EHRs and E-prescribing, decision support, tracking delivery of care, coordinating with a care support system, and feeding back experience with new drugs and treatments, we cannot create a modern health system that will be able to deliver state of the art care and, equally important, keep the research engine going that discovers and develops new drugs, technology, and diagnostic and treatment capabilities. I think we can accelerate the pace of change through good policy but will slow that pace if we concentrate on access without addressing cost. Luckily, medical science is at a point that enables us to address cost in a more effective and fair manner than just cutting reimbursements or not covering known treatments, but that must be rigorously coordinated with access to all or we won't achieve either. That is why this discussion is so important.

Carol Raphael President and CEO Visiting Nurse Service of New York

Posted June 24, 2008, 2:22pm

I agree with previous commenters that the question may not be whether a new model is needed, but rather, how to more rapidly implement and evaluate the new models, and more broadly disseminate the models that work. A successful chronic care model depends on a few key elements, such as the adoption of the perspective that care extends beyond a single encounter or procedure; an accountable coordinator of care who helps the patient anywhere in his/her care cycle; the engagement of patients and families in care management; and alignment of incentives across stakeholders to reward preventive care and collaboration and integration across settings.

One practical approach is to unleash the power of health information technology (HIT) as a "virtual integrator." HIT can help to facilitate information-sharing across disciplines, providers and settings, as well as communication with patients and their families. HIT can also assist care providers with decision-making at the point of care and reducing errors. While at the federal level, there is some movement to create standards and interoperable health information systems, much of the work on the ground is being done at the state level, with maturity of systems varying by state.

Susan Dentzer Editor-In-Chief Health Affairs

Posted June 24, 2008, 3:22pm

Adding to the comments just posted on health-information technology: it's my impression we have only begun to explore the extension of technologies into the home environment to help people with the behavior-change and medication compliance issues others have already cited.   There are prototype technologies under development at companies like Intel that prompt users in the home to take medications or monitor their blood sugar levels, and that can also allow others—health care personnel, relatives, etc.—to know the state of compliance.

And while we're at it, we should include the importance of taking a second look at insurance or benefits coverage issues that could militate against prescription drug compliance.  The well-known example of Pitney Bowes is applicable here.  The company discovered that one real barrier, especially for its lower-paid employees, were even minimal drug co-pays on generic drugs commonly used in various chronic disease treatments.  The company was actually better off waiving these charges and making these medications available to its covered personnel and their dependents for free.

Lawrence Casalino Physician and Health Services Researcher University of Chicago

Posted June 24, 2008, 5:08pm

Information technology is very important, but information technology is not a substitute for organization. As long as we have a delivery system that is fragmented as ours is now, and as long as payment methods make it possible for the system to remain fragmented and for physicians and hospitals to simply focus on providing as many high net revenue services as possible, IT and other initiatives (e.g. disease management programs without physician involvement) will likely be marginal and relatively ineffective (and, of course, there will be little incentive for smaller physician practices, especially, to invest in IT).

It would be possible, with Medicare taking the lead, to use several means to reward organizations (e.g. “accountable care organizations,” as recently advocated by MedPac) that provide high quality, efficient care for populations of patients. These could be, but need not be, integrated delivery systems in which physicians and hospitals are in the same ownership structure, large multispecialty groups that align with hospitals, IPAs, or PHOs. The latter, of course, have mainly performed poorly to date, but it is not clear whether this is because of inherent deficiencies or because the incentives for good performance are not large enough.

Many patients and physicians appear to prefer the human scale, small practice setting; if these practices were part of systems that could assist them with things (e.g. IT and nurse care managers) that they cannot provide themselves, they might do well. The ideal payment/reward structure would not force physicians or hospitals into any particular types of organizations, but would reward the types of organizations that perform well – physicians and hospitals (and patients) could then vote with their feet about where they want to be.

Nancy Johnson Senior Public Policy Advisor Baker Donelson

Posted June 24, 2008, 5:19pm

The comment about the structure of insurance by Susan Dentzer is very important. The work of Mark Fredericks and others at the University of Michigan Center for Value-Based Insurance Design is in my mind extremely important because it will help employers restructure their insurance plans in a way that employees can support but that will also reduce costs.

The recent requirement for public employers to account for the future liability of their health benefits is going to put benefit structures back on the bargaining table. With the work of the Center and all the public and private sector experience developed in recent years, we may be able to move state and municipal employee programs, and even Medicare with adjustments, into a more preventive structure with patient participation and support more effectively structured in.

With the greater incentives to adopt health IT that are likely to come out of this Congress, cost pressures, and knowledge of the value of targeting patients with chronic illnesses with a broader care coordination and support services package, it just might be possible to see a serious increase in the pace of system change. Policy changes will matter, and passage of the Medicare bill as currently moving and Health IT with a few bugs worked out could give the next president the building blocks of a delivery system that could carry health care for all at a cost we could afford by spending our current money more effectively.

Susan Dentzer Editor-In-Chief Health Affairs

Posted June 24, 2008, 5:40pm

We must not omit the fact that a "new model" of chronic care delivery must incorporate serious efforts at secondary and tertiary prevention, in addition to care and treatment. This of course raises all the conventional payment issues – e.g., incentivizing providers to engage in these sorts of activities as much as in delivering treatments.

In the interests of containing costs – and possibly improving effectiveness –  it's also worth stressing the importance of team-based approaches to delivering this broad spectrum of care. "Task-shifting" and use of non-physician personnel may also be critical. My understanding is that Kaiser Permanente is exploring ways to deliver as much timely and cost-effective care to patients as possible – and at the same time, keep them away from physicians until they really need to be seen by one! Other systems, too, are exploring ways to have all non-physician health care personnel work up to their very maximum in terms of scope of practice. Why couldn't a well-trained "community health worker" be put in charge of helping heart attack victims in a given neighborhood comply with medication, undertake changes in diet and exercise and engage in other steps necessary to avoid a second event?

Philip Howard Founder and Chair Common Good

Posted June 24, 2008, 6:25pm

It's getting near the end of our first day of discussion, and a lot has been put on the table. I know it's hard to herd cats, or experts, but I would be very interested in how each of you would advise Obama or McCain on chronic care. Maybe your hypotheses will take us into tomorrow's discussion.

Based on what I've read so far, here's what I'd say:

1. Chronic care is too important, to patients as well as to the public healthcare dollar, to be left to the haphazard patchwork of health care in America. Nor do consumer-driven models seem to work--part of the problem is that people don't take care of themselves, and the public ends up paying. The White House should get a preliminary report, as soon as possible, on the costs and effectiveness of chronic care in the US. 
2. Federal reimbursement of chronic care should not be fee for service, but fee for results.  Chronic care must include affirmative outreach, as several of you have suggested. Private employers should also pay for results. [Has anyone devised a model or metrics for such a reimbursement plan? If not, it should be a priority.]
3. A panel of ethicists should recommend whether and how to align incentives to encourage people to take better care of themselves--both as patients and with healthy lifestyles.  Should reimbursement be reduced to those who act in self-destructive ways?

Lawrence Casalino Physician and Health Services Researcher University of Chicago

Posted June 24, 2008, 11:26pm

I couldn't agree more, Susan. As a naive young family physician in private practice years ago, it became clear to me that most of what my patients needed, in terms of acute, chronic, and preventive care, could be very effectively handled by my nurse and me over the phone (this was pre-e-mail and pre-the chronic care model). The patients loved it, as well, because they didn't have to leave work, get a baby sitter, lug the kids along, wait for a half hour in our waiting room, or pay. We did this for 20 years, seldom getting home before 9 PM, and earning very little money–the more patients we had, the more unpaid work we did each day. I believe that with proper payment systems, physicians in many specialties might see relatively few patients face-to-face on any given day (albeit in some cases for longer visits), though they would, through a variety of means, actually provide care for many more patients per day. It might be a good idea to start with a clean slate and ask: We have highly trained and motivated individuals–physicians. What is the best way for them to spend their time? It probably is not rushing from patient to patient as fast as possible.

Bruce Vladeck Executive Director Ernst & Young's Health Sciences Advisory Services

Posted June 25, 2008, 1:24am

I'm afraid I have to respond to two of the earlier comments. David Kendall suggests I am one of three commenters who does not support pushing implementation of new chronic care models. Indeed, I do support some of the more promising models; I just am not convinced they will save us any money. But that is, and should be, beside the point—if we can give better care, we should do it. I'm not crazy about the Wagner model, but that's not the only approach extant to improving chronic care.

Which provides a comfortable segue to my disagreement with Nancy. In fact, most of what we know about better ways to deliver chronic care has come through Medicare—or more often and more relevantly—Medicaid demonstration projects, going as far back as New York's "Lombardi program" in the late '70s and the channeling demonstrations of the early 1980s. Indeed, Medicaid is especially relevant here, because it covers more people with chronic illness than any payer, and has long encouraged programmatic experimentation.

A final note—I agree with many of the commenters that we desperately need new ways to pay for primary care—whether we call it a "medical home" or anything else—not only to improve chronic care, but for lots of other reasons as well.

David B. Kendall Senior Fellow for Health Policy Progressive Policy Institute

Posted June 25, 2008, 9:05am

Thanks for a terrific discussion yesterday. We heard many good ideas and observations. Let me second Philip Howard's suggestion that we focus on what each us would recommend to the next president. Please be as specific as possible.

Yesterday, several participants mentioned specific models for chronic care: medical homes (John Rother), the Wagner chronic care model (Peggy O'Kane), and accountable health organizations (Lawrence Casalino). Are these models different enough that they should be pursued separately or should there be a concerted effort around a single model?

Nancy Johnson and Carol Raphael suggest what's key is to rapidly implement and learn from demonstrations of chronic care models and disseminate the results. How exactly can we do that? Susan Dentzer reminds us that chronic care also depends on health insurance benefits. What is adequate coverage for chronic care?

More generally, is framing chronic care as a goal for reform productive or not? Arnold Relman and Bruce Vladeck say no while Tim Jost, Troy Brennan and others say yes. Jack Wennberg sees a more productive debate over end of life care. More discussion will help readers render judgment on that important question.

Timothy S. Jost Robert L. Willett Family Professorship of Law Washington and Lee University School of Law

Posted June 25, 2008, 9:16am

To address Philip's points made last night, I agree with 1, but have concerns as to 2 and 3. Paying for results is great in theory, but in practice presents a host of challenges, both technical (what results do you pay for? how do you adjust for high-risk patients?) and in terms of policy (what effect will it have on racial disparities? how do you account for patient preferences?) The key issue, I think, is finding a way to move away from the "silo" approach to payment found in Medicare and in most private plans, and to pay instead for coordination of care, taking into account outcomes, patient satisfaction, and cost. Larry Casalino has done some good work on this that he would perhaps like to say more about.

I am also concerned about Philip's third proposal. There are lots of reasons to stop smoking or to reduce weight. I am not sure what additional incentives would make a difference for those struggling with these issues. Reducing payment for care seems to me to be exactly the wrong approach. More promising approaches might include 1) making programs to help with these issues readily accessible to those who want to take advantage of them, 2) non-health care-related public policy interventions, like reducing government subsidies for unhealthy foods and making healthy foods more available to the poor.

John Rother Group Executive Officer of Policy and Strategy AARP

Posted June 25, 2008, 9:22am

My advice to the candidates would be different than Phil's:

1. Chronic care is where the money is in health delivery, so it needs to be a focus for delivery reform. Start with the medical home, but move forward with reimbursement changes to reward team-based care and outcomes.
2. We need a renewed emphasis on health promotion. We shouldn't punish those with chronic conditions, but we should make doing harmful things more difficult and expensive and doing beneficial things easier and cheaper. We need to support school nurses, for example, and tax sodas and transfats.
3. Manpower policy is crucial to our future ability to deliver adequate and affordable care. Focus on primary care and nursing, and limit fee increases to specialists.

Brent James Chief Quality Officer and Executive Director Intermountain Healthcare

Posted June 25, 2008, 10:00am

Wow! This will teach me to be a little tardy in engaging in the conversation. Just to start addressing topics that have been raised so far:

- at least 27% of all Medicare spending happens in the single episode of care that concludes with death (I recently had to track this down in the research literature). Of course, many Medicare patients die from chronic diseases, so it is a little hard to directly compare the costs of chronic disease versus the costs associated with a terminal care episode. I don't recall the proportion of all Medicare spending associated with major chronic diseases, but know that Jack Wennberg has it close to hand.

Intermountain has had some real success in managing chronic diseases. Several of the earlier comments mentioned some of what we have come to believe are critical points: specifically, successful management appears to require (1) good data systems (2) embedded in an organizational structure.

The Dartmouth Atlas analyses identified Intermountain as one of the (relatively) most efficient care delivery systems in the country (along with Mayo Clinic). They estimated that, if other care delivery regions showed similar performance, the cost of Medicare around chronic disease would fall by more than 30%–I recall that that's around $150 billion per year–while quality measures would improve. We think that our chronic disease management contributes to that.

Finally, we're not the only group showing these kinds of improvement results. Depending upon the particular clinical topic, many other practices are matching or exceeding Intermountain’s performance.

(Editor's note: Brent continues with a full explanation of Intermountain's approach in this PDF.)

Carol Raphael President and CEO Visiting Nurse Service of New York

Posted June 25, 2008, 10:12am

I want to support John Rother's advice to candidates. I, too, believe chronic care needs to be a linchpin for reform of the delivery system. I think reimbursement does need to reward enhanced primary care delivered by both physicians and nurses in office and home settings and team-based care, but also care organized across sites. Pay-for-performance measures should not again be siloed, but should be focused on outcomes that require integrating care across settings. However, I am worried about creating new entities and additional layers instead of bolstering those closest to patient care.

Workforce policy does need increased attention as well as suggestions on how to do health promotion effectively so one helps to support people in changing behaviors, rather than simply throwing more information at them.

Bruce, I am curious as to why you are not crazy about the Wagner model?

I would be interested in ideas people have as to how to disseminate results more quickly and how to bring some successful models to scale.

Peggy O Kane President National Committee for Quality Assurance

Posted June 25, 2008, 10:20am

The Wagner model is conceptual and can be implemented in various ways—thru direct-to-patient disease management or planned, integrated care at the delivery level, as in a group practice medical home.

This is part of a package of needed reforms: we also need to be much more disciplined about what gets delivered (proposals for comparative effectiveness address this). We need a payment system that rewards true efficiency—high quality care with minimal waste. We also need an agenda for wellness that works within health care and beyond. The specter of the increased burden on chronic disease caused by obesity needs to be addressed at the source.

And I agree with John Rother that we need to better understand how to activate and motivate patients to maintain their health. This is a tricky business, and I understand Bruce Vladeck's concerns. But I think there is much of value to be learned here that is in the genuine interest of patients themselves and of society.

Timothy S. Jost Robert L. Willett Family Professorship of Law Washington and Lee University School of Law

Posted June 25, 2008, 10:42am

I would also question the argument raised several times yesterday that the private sector is better at addressing these problems than public programs. There is good and growing evidence that other countries with public health care systems do a better job than we do in providing care to the chronically ill. See in Health Affairs: Toward Higher-Performance Health Systems; On The Front Lines Of Care.

In particular, prevalence of medical homes and health care IT, prompt access to primary care including after-hours access, and coordination of care are better in a number of other countries.

The MMA established "special needs plans" as a special category of Medicare Advantage plans to provide coordinated care to dual eligibles, institutionalized beneficiaries, and beneficiaries with chronic diseases. There are almost 800 of these plans in operation, but my impression is that they have not had a major impact on improving care. See Kaiser Foundation's Medicare Issue Brief: Do We Know If Medicare Advantage Special Needs Plans Are Special?; See Center for Medicare Advocacy Report: Recommendations for Medicare SNPs.

This was an opportunity for the private sector to establish innovative approaches to providing coordinated care in Medicare. If there are special needs plans’ success stories, I would like to hear about them.

Finally, I would point to an article in this morning's New York Times illustrating the difficulties we face in reforming our system. A bipartisan effort seems likely to defeat competitive bidding for durable medical equipment, a promising program to reduce Medicare costs.

Until we can get beyond crass interest group politics in running our public programs, there is little hope for health care cost control.

Brent James Chief Quality Officer and Executive Director Intermountain Healthcare

Posted June 25, 2008, 12:05pm

To return to one of yesterday's topics, the Dartmouth CECS group has shown massive geographic variation in health resource consumption in terminal care delivery episodes, after adjusting for common co-factors (e.g., burden of co-morbid disease, ethnicity, age, and gender) despite the fact that all the patients analyzed are in an identical health state (dead). This variation persists among academic medical centers, and among the "Best 100 Hospitals" from U.S. News & World Report. The Dartmouth group has also shown a strong association between total expenditures and quality of care. Unfortunately, the relationship is negative: More spending is associated with worse patient outcomes.

Dartmouth used mortality as their quality indicator, but other groups have shown parallel results using other quality of care metrics. Finally, the Dartmouth group has shown that spending during the terminal episode very accurately predicts spending before a patient enters the terminal episode, at 2 years before death (published) and at 5 years before death (still unpublished, I believe). In other words, this is a phenomenon closely related to beliefs and practice patterns in a local medical community. Finally, the Dartmouth group showed a strong association between spending (at any point - before or at the terminal life episode) and available supply of hospital beds and specialists, for a list of 13 common chronic diseases. Hence the term, "supply-induced demand."

Peggy O Kane President National Committee for Quality Assurance

Posted June 25, 2008, 12:25pm

I agree with Brent and Jack that supply-side issues also need to be part of any meaningful reform agenda.

This is a huge political hot potato. Actually, a number of the central elements of meaningful reform have a very difficult political road.

I keep coming back to the fact that there are lobbies for all the interested parties but there is not a very effective constituency for the public interest.

Susan Dentzer Editor-In-Chief Health Affairs

Posted June 25, 2008, 12:50pm

Here is my dream proposal for anybody running for President:

Echoing John Rother, "it's chronic care, Mr. (or Ms.) President." Chronic care is 75% of our health care spend and it is indeed where the money, inefficiency, overuse and underuse, not to mention poor quality and lack of patient safety really come home to roost.

So the federal government needs to throw its entire weight into righting this situation. Here's one way to proceed:

1) Create a new part of Medicare—Part E, for Chronic Care Management. The comprehensive health care for those who enroll in Part E will be delivered by organized care delivery systems.

2) Anyone enrolled in Medicare or Medicaid is eligible to enroll once they've been diagnosed with at least one of any number of chronic conditions.

3) For those who enroll in Part E, all premiums that they might otherwise have paid to Part B of Medicare are either discounted or waived.

4) As it did for insurers wishing to offer Part D plans, the government will develop a series of specifications as to what the new organized chronic care delivery systems (OCCDs for now!) have to provide.

5) The new OCCDs would be considered "safe harbors" under state scope of practice laws so that the systems could innovate in terms of who could provide care. What would be the incentive for states to go along with this? The feds would agree to pick up a portion of what would normally have been the state share of Medicaid payment for each Medicaid patient who enrolled in an OCCD.

6) The government puts all this out to bid, as it did with Part D, and new OCCD's are allowed to organize themselves accordingly. The system gets up and running as, in effect, a giant 10 year demonstration project, with a clear agreement that it will be studied along the way and fixed over time -- perhaps even having to be reauthorized at the end of the 10 year period, to allow major fixes to be made.

My two cents! I welcome comment.

Peggy O Kane President National Committee for Quality Assurance

Posted June 25, 2008, 2:17pm

I couldn’t agree more that real reform of the health care system needs to come with the full support of the federal government. The sheer size of our health care spend—2-plus trillion dollars a year—is a very powerful inertial force, as the article in the Times that Tim referenced earlier indicates.

As part of a workgroup known as the Quality Crossroads Group, we proposed five building blocks towards a high-performing health care system, which include:

•   A national center for effectiveness research

•   Models of accountable health care entities capable of providing integrated and coordinated care

•   Payment reform to reward high-value care

•   A national strategy for performance measurement

•   A multi-stakeholder approach to improving population health

Implementing any one of the five above building blocks—or Susan’s proposed Medicare Part E—would require broad support from health care thought leaders, bipartisan support in Congress, and the strong support of the next President.

Timothy S. Jost Robert L. Willett Family Professorship of Law Washington and Lee University School of Law

Posted June 25, 2008, 2:41pm

Susan raises an important point that health care reform to address chronic illness requires not only reform of our health care financing system, but also of our legal regulatory system (specifically, she mentions scope of practice laws). Ezekiel Emanuel and I published an article in the June 4 issue of JAMA identifying a number of legal and regulatory barriers to health care delivery reform (including the anti-kickback, self-referral, antitrust, tax exempt organization, certificate of need, and incentive-to-reduce-services laws).

We proposed the establishment of a commission to waive compliance with laws on a health care system by health care system demonstration project basis to establish an evidence base for further legal reform. Whether or not this is the right approach, some approach short of wholesale repeal of all laws regulating health care needs to be found to allow delivery system innovation.

Arnold Relman Professor Emeritus of Medicine and of Social Medicine Harvard Medical School

Posted June 25, 2008, 3:32pm

I have been following the discussion with great interest. There are many good ideas on the table (and some not-so-good), but they all deal with pieces of a complex medical care system, in which each piece is related to and affected by every other. The problem of chronic care can only be understood and addressed by viewing the system as a whole.

Our current system simply isn't viable anymore and we can't save it by just dealing with one part, e.g., chronic care. We will have to reform the entire system. I have suggested what needs to be done and how we might start, in a little book I wrote last year, A Second Opinion. Rescuing America's Health Care, (Public Affairs, 2007). There may well be better approaches than the one I suggest, but what seems quite clear to me is that tinkering with the parts of our failing system will not save it.

Philip Howard Founder and Chair Common Good

Posted June 25, 2008, 4:49pm

Finally, Tim Jost has touched on a part of this that is near and dear to my heart—legal constraints. Can we all agree that coming up with new models or frameworks for chronic care requires a clean legal slate? Trying to design a system that can grind through all the requirements of the Rube Goldberg regulatory structure is almost certainly hopeless.

Many of you are landing on the idea of a "medical home." I'm very interested in the practical aspects of this—specifically, the need to have providers responsible over a period of time. That means someone who changes jobs shouldn't have to change providers. How would that work? I'm also interested in incentives to the patient—if sticks don't work (we want them to seek out care not pay extra for care), then what are the carrots?

On Peggy O'Kane's realpolitik point, getting past interest groups is certainly a major obstacle even to tiny reform, not to mention a complete overhaul. That's why, I believe, it is important for thought leaders from different perspectives to come together in forums such as this one, and seek common ground. If a quorum of this group can arrive in the same zip code for what needs to be done, that can be shaped into a policy statement and carried forth to the candidates and the public.

Today's discussion has been very exciting. What I'd like to ask you to do is put more meat on the bone. What would these reforms look like? What do we have to undo to get there?

Nancy Johnson Senior Public Policy Advisor Baker Donelson

Posted June 25, 2008, 5:09pm

I agree that the next President has to focus on reintegrating care .... how to incentivize care coordination, how to go beyond coordination to health support, how to develop these concepts through a variety of models so that all areas, rural and urban, communities of varied cultural and community structures, and all ages of patients, can have access and payment for this different set of services and assure that they improve quality and help control costs. Thus, reform of payment silos and regulatory barriers must be high on the agenda of the next President, as well as such matters as measuring quality and transparency, I believe such changes will increase payment to family physicians and is absolutely essential, with telemedicine, to keeping rural health systems alive.

Equally high on that agenda must be an aggressive effort to help all providers adopt health IT, as technology is essential for the delivery of integrated care. Incentives based on practice size and profitability that vary from grants to loans must accompany deadlines for adoption. Sufficient funding is necessary to assure Quality Improvement Organizations (QIO) technical support to assist with adoption, maintenance, and exploitation of technology for care improvement.

A similar government capability in the manufacturing area made all the difference in small manufacturer take-up of the technology and organizational changes necessary to meeting global competition, changes similar to those that must occur in the health services delivery system.

But, having written the medical home demo (as well as many other demos), I am now discovering software developments that can reward a physician for the quality of care and care coordination that we know matters without paying for a capability that may or may not be used, or used rigorously and effectively. In the Medicare Health Support demos we learned a tremendous amount about what works, doesn't work, and will work with new program designs. Timely data is also key to success in the new era and impedes government’s ability to lead the way in managing care. Lastly, one size doesn't fit all!!!

Nancy Johnson Senior Public Policy Advisor Baker Donelson

Posted June 25, 2008, 5:47pm

I don't think you can get a clean legal slate. We still have to get from here to there. All the providers are loaded with Medicare law, regulation, and all those letters changing terms and conditions of participation that move constantly from DC to hospitals, etc. I tried to modernize the cost reports, IG rules governing Stark issues, rules governing physician office audits so there would be some fairness as well as accountability. Very hard. Need more than this kind of dialogue to methodically identify changes in laws and regulations that we all agree need changing to allow the system to reorganize. Then there are those we don't agree on. But doing the former would be a great bipartisan contribution!

Also, there is some rich and relevant experience on incentivizing patient involvement that needs to be studied and applied because care management and support depend on better communication and greater trust in the delivery system.

David B. Kendall Senior Fellow for Health Policy Progressive Policy Institute

Posted June 25, 2008, 5:58pm

Great discussion today! To help us flush out some workable policy options, here are some conflicts and agreements that I see developing:

Susan Dentzer proposes an intriguing new federal program in Medicare modeled after the prescription drug program where chronic care patients could choose among competing health organizations. But what about Bruce Vladeck's point that the states have been leading much of the innovation in chronic care through Medicaid? How would a federal Medicare program help workers with chronic conditions in job-based coverage?

Brent James points out that a major obstacle to better chronic care is the local patterns of medical practices that don't add value and sometimes do harm. Can Peggy O'Kane's idea for a national strategy for performance measurement reveal the waste? Or do we need another strategy as well?

Tim Jost points to legal impediments to implementing chronic care models. Yet Brent James' Intermountain Healthcare has developed excellent chronic care at lower cost without such legal relief (and despite a payment system that discourages good chronic care). What's a shorthand way to show elected officials that legal relief is necessary?

Nancy Johnson suggests a carrot and stick approach to achieve physician adoption of electronic health records, which are critical for efficient chronic care. But how much can we expect Congress to foist upon doctors if we also, as John Rother suggests, limit fee increases to specialists under Medicare. How can reform also lift up health professionals who today are bearing much of the burden for our dysfunctional system?

Susan Dentzer Editor-In-Chief Health Affairs

Posted June 25, 2008, 6:02pm

To Philip's question – what do these reforms need to look like – my answer is something in between a sweeping national reform and a major national demonstration project or series of projects. Let's get policymakers to agree that we have a huge problem in chronic care and that we really need to innovate. Let's create room for these new organized care delivery systems to come in under new payment structures, safe harbors on scope of practice and the other existing statutory and regulatory impediments to innovation. Let's incentivize providers and patients alike to try them out. Let's create a research mechanism to study them and compare them to chronically ill people who stick with existing systems of care and develop the data to compare outcomes and expenditures/savings. Then let's quickly feed back information to policymakers about what works and what doesn't, so they can scale back the things that aren't working and scale up the ones that are.

Lawrence Casalino Physician and Health Services Researcher University of Chicago

Posted June 25, 2008, 6:09pm

In response to David Kendall’s question this morning: I believe that all Accountable Care Organizations would have the characteristics of medical homes, but not all medical homes would be part of Accountable Care Organizations – the latter would range from large to very large; a medical home might be a very small physician practice. I think it is critical that patients not be forced into choosing a medical home or an ACO, or staying in one once chosen, or required to access services only through their medical home or ACO. The system could function well without that. Health plans, Medicare, and Medicaid could do much to educate people about the advantages of having an medical home and/or being a patient of an ACO; the proof, over time, would be in the pudding. As for the chronic care model, it is not an organizational form but a reasonably coherent set of ideas, most easily implemented by larger organizations, but many of which could be done by smaller practices if the financial incentives were there.

There will be an article in the July 2 JAMA, by Steve Shortell and me, on ACOs. Additionally, the New America Foundation has commissioned a series of articles on reforming Medicare, with Bob Berenson and Len Nichols serving as editors; I’ve written a paper for this project that contains much proposed detail about ACOs (and their relationship with medical homes). Tim Jost has written a long paper, for the same project, on the legal and regulatory changes that would have to occur for these ideas to become reality.

Chronic care is important, but I think it would be a mistake to create a Medicare Part E for chronic care. That would fragment the system still more. In daily practice, there isn’t – and shouldn’t be – the clear separation between chronic care, acute care, and prevention that is assumed by proposals to create a separate system for chronic care. If we’re going to try for a major reorganization of the delivery system, we may as well make it comprehensive.

Brent James Chief Quality Officer and Executive Director Intermountain Healthcare

Posted June 25, 2008, 8:12pm

Tuesday night, we were set the task of describing how we would advise the next president regarding health care reform for managing chronic illnesses. Two ideas have appeared in the conversation today that I wanted to re-emphasize. I think they are the heart of “getting it right.”

1. Good chronic care delivery requires good information systems, in order to move from episodic to continuous care. The key issue around health IT is not funding–properly implemented (now there’s a loaded term!) a good EMR can be a real money-saver even for small practices. The key is interoperability. Tommy Thompson established a series of committees that identified information standards for all of the major subsets of practice where an ability to easily share data are key. Mike Leavitt’s AHIC work, and the continued efforts of ONCHIT, have kept that moving ahead. We still need, though, a mechanism for software vendors to generate standards; and an independent body to certify software as meeting those standards. This is classic, appropriate, work for a central authority. We have very strong models from other industri