Special report: Chronic care crisis

In the United States, roughly 75% of healthcare expenses are devoted to the management of chronic conditions, according to the Centers for Disease Control and Prevention. As the population continues to age and longevity continues to increase, it is very likely that payers will find their work with chronic disease patients to be among their most important and enduring relationships.

“We’re all getting older, the country is grayer, we’re recognizing that there are things we need to do to stay stronger longer,” says Roy Beveridge, MD, chief medical officer for Humana Inc. “This is why making a change from being an insurance company to a health partner is in Humana’s interest. We want to keep people healthier longer, because then they’re our members, our patients, longer. Everything is aligned.”

The widespread systemic implications of chronic conditions, as well as the diligence required for their long-term management, often spill over into mental health as well, says Niyum Gandhi, a partner in the Health and Life Sciences division at Oliver Wyman.

“The comorbidity rates of all of these chronic conditions and depression are through the roof,” Gandhi says. “So it’s not just a physical issue; it’s a combination of physical, psychological, social, functional and pharmaceutical. And if you don’t address all five, you fail.”

Identifying chronic patients

One crucial aspect of successfully managing chronic care patients is to identify them earlier and take action steps to help mitigate the disease progression, says Jan Berger, MD, of the Center for Patient Safety Research and Practice at Brigham and
Women’s Hospital, in Boston.

“This involves medical claims, patient self-reports and referrals into the system, whether by the doctor or the health plan,” Dr. Bergersays. Health risk and lifestyle assessments, such as biometric screenings, are also important.

“There are people who don’t know they have a health problem,” she says. “As you get a number of these risk factors, they are either due to chronic disease or they can actually cause a chronic disease. So it’s important to catch them as early on as possible.”

Health fairs and other programs designed to make patients aware of their risk factors for chronic disease can help, she says.

Optimizing claims data

If used efficiently, claims data also can play a meaningful role in identifying and managing chronic care patients, Dr. Beveridge says, adding that investing in technologies that allow plans to receive claims information in real-time can be beneficial. 

“If Mrs. Smith comes into the hospital on January 1, sees doctors for the next month and we don’t get claims data until June, at that point, the data isn’t very helpful to us. But if we get data in almost real-time, it can be very helpful,” he says. “It’s all about the velocity and the rapidity of getting the information.” 

Technologies at Humana provide up-to-date medical information on patients, Dr. Beveridge says. 

“If Mrs. Smith goes into the emergency department, gets a prescription and then goes to her primary care doctor the next day, the system we have allows us to see that,” he says. “We can also see from this little bit of data whether a CT scan was ordered and what laboratories were ordered, and can push it back into the primary care doctor’s or hospital systems’ data and say, ‘This is what happened to your patient last night.’”

The system at Humana is also linked into pharmacy and electronic health records  (EHR) data, Dr. Beveridge says, and this cumulative information can begin to paint a clear picture of a chronic condition.

“We’ll look at the data from the EHR, from the claims, from the hospital visits and laboratory data, and if we can see that someone’s kidney function is high-and we know they have diabetes-then the logic of this sophisticated tool says, ‘Has this patient had hemoglobin A_1c checked lately?’ And with the information we have, we can begin to look for the gaps in care,” he says. 

A focused approach

Understanding the risks specific to a practice’s patient population is another key component to delivering the best chronic care management, according to Julie Schilz, BSN, MBA, director of primary care strategies at WellPoint. 

“‘Primary care’ could mean an independent practice or practitioners within a large accountable care organization [ACO],” she says. “The key point is to maximize your EHR, understand your patient population, pull the data on a regular basis and use the ICD-9 codes to manage your patient population.”

Schilz says the chronic care focus generally differs based on the type of practice. 

“If you happen to be an internal medicine practice, you may see more patients with congestive heart failure. If you’re in family medicine, you may see more diabetes,” she says. “It’s important to focus your structure and your team on how to deliver evidence-based care for patients with chronic disease.”

While implementing this philosophy might look different for each practice, Schilz says the concept and collaboration remain the same. For example, larger organizations might be able to purchase software or use standardized algorithms for running EHR data, while small, independent primary care practices can simply pull EHR data by searching which patients have diabetes.

“There are different ways to do it based on your size and structure, but everyone can have a role in this,” she says. 

Opt in/opt out?

The question of whether to present disease or health management programs to patients on an “opt-in” or “opt-out” basis is truly one for the ages, Dr. Berger says.

“It’s a very interesting and controversial question,” she says. “Should we concentrate on patients who are ready to make a change, or should we be helping people who are not quite ready to make a change, hoping that by making small changes they’ll become more willing over time to make bigger changes? There’s no easy answer.”

Schilz says WellPoint has found more success with an “opt-out” enrollment method for its disease management program, called
Condition Care.

“Through our programs, our nurse care managers help individuals to be successful with their care plan with their physician by offering additional education about their condition, coordinating their health benefits, empowering them with questions to ask their doctor and connecting them with local community resources,” Schilz says. 

Berger says the question of “opt in” or “opt out” doesn’t need to be entirely black or white.

“Depending on what the program is, there may be higher-touch or lower-touch support,” she says. 

Dr. Beveridge says Humana’s dataset and reporting system don’t necessarily need to address the “opt-in/opt-out” question directly. 

“What we can do through our system is circle back to the primary care doctor and say, ‘this is what’s going on’ and identify the gaps in care,” he says. For example, noticing through data that a patient hasn’t had their glucose checked in four months, let alone a colonoscopy in the last five years. 

“It’s not really opt in or opt out, it’s providing data to allow the clinical interaction to be optimized,” Dr. Beveridge says. 

By having a full picture of the patient’s risk factors and the possible gaps in care, primary care physicians are armed with more information to encourage patient compliance, Dr. Beveridge says.

“You can’t really force someone to take care of themselves,” he says. “What you can do is give the information to the clinician-you can even give it to the patient, if the patient wants it-and maybe the patient will eventually decide to do something about it. But it’s important to have that engagement.”

An alignment of goals

One important change to chronic care under  the Affordable Care Act (ACA) is a renewed emphasis on the primary care practitioner.

“The ACA tries to get people to the
primary care physician,” Dr. Beveridge says. “It emphasizes the role of the primary care doctor in monitoring diabetes, heart failure, cancer screening, all of those important things.”

ACA has opened up access to healthcare for many Americans, and eliminated copays and coinsurance for many preventive services.

“What you’re seeing is health plans decreasing the financial barriers to a member seeing their primary care doctors” for common preventive services, she says. “They’ve aligned incentives between providers, payers and patients, and so the tug of war, if you will, isn’t going away, but it is being reduced.”

Initiatives through patient-centered medical homes and ACOs are examples of this aligned approach. Dr. Berger is hopeful that in the future, some of the newer collaborative structures will rely more on allied healthcare professionals to address ongoing preventive care issues with patients. 

 “Doctors are not trained to have that conversation, so it is my hope that through the ACA, the model of ‘it takes a village’ will include allied healthcare professionals,” she says.

Implementation of a village-based approach would require mutual trust, she says.

“Providers don’t trust providers, providers don’t trust payers, and members or patients pretty much don’t trust anyone,” Dr. Berger says. “There is a paucity of trust, and we have to regain that trust through aligned incentives and better understanding,.”  

Jennifer Byrne is a freelance healthcare writer based in Glassboro, N.J.

Additional coverage

Innovative ACOs: Rebuilding chronic care management from the ground up