What will it Take to Improve Care for Chronic Illness for the Population?

Ed Wagner, MD, MPH

MacColl Institute for Healthcare InnovationCenter for Health StudiesGroup Health Cooperative

Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation

Step 1: End the complacency!• U.S. 30th in life expectancy (Cuba is 29th)

• Rank among the lowest of Western countries in other health indicators

• 40-50% more expensive than any other country

• Nearly 1 in 6 have no health insurance and they have a 25% greater mortality rate

• Tragic racial, ethnic and income disparities

What will it Take to Improve Care for Chronic Illness for the Population?

Johns Hopkins U.S. Survey about Chronic Care: % Agreeing With

Public MD’s Policy-makers

People with chronic conditions usually receive adequate medical care

48% 45% 22%

Gov’t programs are adequate to meet the needs of people

with chronic conditions38% 20% 16%

Health insurance pays for most of the services

chronically ill people need37% 28% 23%

Why focus on chronic illness care?

• Primary care dominated by chronic illness care

• Clinical and behavioral management increasingly effective, but complex and expensive

• Inadequate reimbursement forcing primary care to increase throughput while limiting clinical staff—the hamster wheel

• Roughly 50% of Americans not receiving evidence-based chronic illness care (Quality Chasm) and only 25-40% have their condition under good control

• Trainees choosing other specialties

• Loss of confidence in primary care by policy-makers and funders

• Talk of the “demise of primary care”

Why the Focus on Chronic Illness Care?

• Over 100 million Americans have one or more chronic conditions

• They account for the vast majority of health care costs

• Roughly 50% of Americans not receiving good chronic illness care (Quality Chasm)

• Situation is worse for the uninsured and racial and ethnic minorities

• Unhappy primary care clinicians leaving practice; trainees choosing other specialties

What will it Take to Improve Care for Chronic Illness for the Population?

Step 2: Find the cause of inadequate care.

IOM Quality Chasm Report:

“The current care systems cannot do the job.”

“Trying harder will not work.”

“Changing care systems will.”

Step 3: Select a strategyThree Options:

1. Assume that competition and computers willimprove care

2. Direct to patient disease management

3. Improve medical care by changing care systems

What will it Take to Improve Care for Chronic Illness for the Population?

Why Effective Medical Care is Essential to Improve Care and Reduce

Costs for Chronic Disease

• The human and financial costs result from poor control of the conditions

• Good control requires appropriate drug treatment, careful follow-up, and changing treatment if needed

• Continuity and satisfaction with medical care associated with better control

What kind of changes to practice systems improve care?

Integrated changes with components directed at:

better use of non-physician team members,

planned encounters, modern self-management support Care management for high risk Links to effective community

resources guidelines integrated into care enhancements to information

systems (registries)

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Outcomes

Lessons learned in chronic illness care improvement

• Chronic care collaboratives have demonstrated that practices can make these changes and improve care

• Mostly reaching early adopters

• Practice redesign is very difficult in the absence of a larger, supportive “system”, especially for smaller practices

• How to help isolated small practices where 80% of Americans receive their care?

• Regional improvement efforts beginning to make make a difference

What will it Take to Improve Care for Chronic Illness for the Population?

Step 4—Reach the Majority of Practices

• Are there lessons from successful large systems like the VA or regions of Kaiser Permanente?

• If so, might they be applicable to communities?

King’s Fund Study of Organizations with Best HEDIS Chronic Illness Scores

Organizational factors supportive of high quality chronic care:

• Strategic values and leadership that support long term investment in managing chronic diseases

• Well aligned goals between physicians and corporate

managers

• Investment in information technology systems and other infrastructure to support chronic care

• Use of performance measures and financial incentives to shape clinical behavior

• Active programs of Quality Improvement based on explicit models

What’s needed to improve chronic illness care for the population?

• Commitment and Leadership

• Measurement (and incentives)

• Infrastructure – IT +

• Active program of practice change

Step 5—Build a regional healthcare “system”

• Care will not improve unless we changethe systems of care

•The goal is to transform health care delivery everywhere healthcare is delivered

•Someone needs to take and thenassure leadership

•Major stakeholders need to be involvedand committed to improvement

Leadership

•Need outcome and patient experience dataas well as process data to assess effort, performance, and improvement

•Practices will have to be able to provide valid and complete data on these indicators; claims will not suffice

•Ideally practices should be able to use these data in clinical care, not just periodically send offmeasures

•Smaller practices need info. and technical support to develop such data systems

•Need strategies andinfrastructure to helpALL practices change their delivery systems

•Strategies – QI methods,Provider networks

•Infrastructure—IT, guide-lines, care managers

•More activated and informed consumers may help pushimprovement

•Public disclosure of performancedata may spur improvement

•Create incentives for providers to make the investments needed to improve chronic care

•Create benefit plans that reward consumers for making cost-effectivechoices

Questions raised at recentconference:

• Does the limited evidence of P4P effectiveness to date reflect problemsin P4P design?

• or Is P4P an inadequate band-aid ona perverse payment system?

• Should P4P more aggressively tryto remove payment barriers, not justadd bonuses?

A Framework for Regional Quality Improvement

Is geographic improvement possible? North Carolina

• State leadership and money has created a visionary Medicaid care system

• Measurement system, Guidelines, Physician networks, Care Managers, Collaboratives

• Financial rewards for participating

• Early results promising

• Plans to extend to include all patients regardless of insurance coverage

•www.improvingchroniccare.org

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