Government agencies, payers and providers are increasingly seeking to simplify care for patients with long-term health conditions.
Chronic diseases – including heart disease, stroke, cancer, asthma, Alzheimer’s, diabetes, arthritis and others – kill and disable more Americans than anything else.
Many also are among the costliest and most preventable health conditions. Combined with mental health care, care for chronic diseases constitutes the majority of the nation’s $2.7 trillion in annual health care spending, according to the Centers for Disease Control and Prevention.
“Obesity is (the most expensive risk factor),” says Kenneth Thorpe, a professor and department chair in Emory University’s Rollins School of Public Health, who also leads international coalition the Partnership to Fight Chronic Disease. “And then the related things that lead to it – diet and exercise, nutrition, lack of physical activity – all of those get bundled up into these increasing obesity rates.”
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Thorpe recently spoke with U.S. News about about slowing the growth in health care spending on chronic conditions and how some new Medicare Advantage provisions could help providers coordinate care for older and sicker patients. The interview has been edited for length and clarity.
Some health conditions like some cancers, obesity and heart disease disproportionately affect nonwhite and low-income communities. How do chronic conditions perpetuate economic inequality in the U.S.?
There’s a couple of things. Obviously, obesity is linked to several chronic conditions like hypertension, diabetes, stroke and so on. Non-Hispanic blacks, 47 percent of them are obese compared with like 38 percent of whites. So the likelihood they have these diseases is much higher. It increases what they have to spend on health care to manage the conditions.
Second, there are data that show that chronic disease is associated with lost productivity and fewer work days. Indeed, even the onset of a chronic condition can take somebody out of the workplace, so that has a family income effect. To that extent, there are already existing average differences between the different races and ethnicities, and chronic disease adds to those differences.
Research indicates that prevention is much less expensive than treatment, but the caveat is that habits and health behaviors can be really difficult to change. What kind of interventions actually work?
The good news is there are interventions like the Diabetes Prevention Program that have for 20 years shown that it reduces the number of new cases of diabetes, high blood pressure and cholesterol, and at the same time saves money. For a general population, if you look at enrolling prediabetic adults into it, it reduces the … transition into diabetes by 58 percent. That’s obviously a covered benefit now by Medicare – that started in April.
The challenge there is going to be: Can we find ways to expand it to other payers? I think the answer is yes, because Medicare Advantage plans – Humana, Aetna, Cigna, Blue Cross plans – will have to provide it, so my hope is they will make that available to their commercially insured populations as well. We’ve been doing some work trying to get state Medicaid plans to cover it and state employee programs to cover it.
There is a platform that’s out there that’s been proven to work – we’re just going to have to get physicians knowledgeable about it and find ways to get patients matched with these programs and get them enrolled. It’s more of an implementation challenge at this point. We have something that works, we just need to have an effective rollout.
You just touched on Medicare Advantage plans. Tucked in the Budget Act were some provisions that allow these plans to cover some nonmedical services, like meal delivery and installing ramps to keep people from falling in their homes. Given the flexibility around how those things could be implemented, how do you see this unfolding?
I think what will happen is the plans will survey the health care needs – particularly the frail population they have, the ones who have multiple chronic conditions – and put together an action plan on what mix of social housing and medical care services would be most effective in keeping these people healthy. Fortunately, we have some good examples at the state level of what are called community health teams. They’re basically teams of nurse practitioners, public health nurses, behavioral health specialists (and others) that work with health care providers to coordinate care for sick patients.
Up in Vermont they have combined the medical component with a program called Support and Services at Home, which has been very effective. That’s certainly a good model to look at how the support and services from at-home programs have integrated with more traditional medical services. To the extent they have that flexibility, it is a really good idea.
It all makes sense – it’s clearly in the plan’s incentives to do anything it can do to reduce costs but keep the patients healthy. Many of these patients who are most troubling and problematic are the ones who have a lot of social and housing needs that previously health plans and providers weren’t able to provide under the medical benefits.
We always hear about how aging will increasingly strain the health care system, but it’s also a huge burden for family and other unpaid caregivers. Do you expect to see more workplace and/or government policies or programs that are designed to support caregivers specifically?
As we continue to evolve in terms of delivery system innovations and reforms, I think that’s got to be part of the discussion, where we’re focusing not only on community-based approaches, but home-based approaches. The independence-at-home type of approach – where you’re doing anything you can to provide health care and social services that allow people to stay at their house rather than going into much more expensive institutional care – is certainly a step in the right direction. It’s something the Chronic Care Act put into place. As we continue to look at opportunities to reform our delivery models, certainly a focus on having the caregiver part of that care team has got to be part of that discussion.
Is there anything you’re working on now you want to mention?
I’m doing some work looking at the growth of health care spending by medical condition. One of my pet peeves is the discussion on cost containment continues to focus the same way it did 20 or 30 years ago on silos of health care spending – drug spending, hospital spending and so on – and what matters is really the overall cost of treating, let’s say, a diabetic or heart disease patient.
One of the things I’m seeing is for many conditions – hypertension, lipids – that relative to 10 years ago, controlling for inflation, that the cost of treating those patients is less expensive than it was. It’s in part because of the broader use of statins and antihypertensives that have been very successful in keeping people out of the hospital and reducing strokes. We’ve had a shift, obviously, from some big brand drugs to generic drugs, which are less expensive.
It seems to me ironic that public policy is moving in a direction that’s focusing on population health management – through accountable care organizations, the new model in Maryland or Medicare Advantage – which is really saying, “We’re giving you X dollars per capita to manage this population, and we’re going to measure their outcomes and share savings with you. How you allocate those dollars to do the best job is really up to you.”
Then on the other side, we have a debate over silos of spending, which to me is a complete disconnect.
Date: August 24, 2018