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Key stakeholders debate the best pathway to healthcare reform

There is a growing consensus among business and healthcare policy experts that the steep hikes in healthcare costs that we have seen in recent years are economically unsustainable, and that the only way to get healthcare spending under control is by implementing fundamental changes in the way we fund and deliver care. Further, it’s clear that the heart of the problem is the escalating incidence of chronic disease in this country and the substandard care that chronically ill patients routinely receive. Study after study suggests that most people receive only about half of the care that is recommended for their conditions, and this inevitably leads to a vicious cycle of spending as preventable complications develop, making care and treatment increasingly expensive.

It’s a complicated problem, but at least it now has the full attention of business leaders, policymakers, and providers. This was evident as key representatives from all of these sectors recently shared their concerns and ideas about potential solutions in a summit sponsored by the Intel Corporation titled “Chronic Care at the Crossroads: Exploring Solutions for Chronic Care Management.” The meeting, held in Washington, DC, on July 17, facilitated a wide exchange of proposals about how to refashion a system largely focused on acute care into one that promotes wellness and prevention.

Costs continue to escalate

Intel Corporation’s interest in sponsoring the summit came, not only from the fact that the company is working on a number of technological innovations related to management of chronic disease, but also because it is providing healthcare benefits to 55,000 employees in this country, noted Craig Barrett, chairman of the board of Intel, in his opening remarks. “We [at Intel] spend somewhere in the range of 600 million dollars [on healthcare] today. By the end of the decade that probably will be closer to a billion dollars a year on healthcare costs,” he said. “And anything that we spend on healthcare detracts from what we can do from a product development standpoint.”

Further, Barrett noted that he is troubled by the fact that the health reforms proposed by most of the presidential candidates deal almost exclusively with how to insure the 45 million people in the country who are now without coverage. “Not many people are talking about what to do in detail to change the way healthcare is delivered, or much about changing the cost of the healthcare system,” he said. “As the baby boomers age and we get more and more people over the age of 60, costs are going to increase. The issue is what can we do about it?”

One of the biggest problems is that the current healthcare delivery system is not geared toward pre
venting chronic illness or taking care of the chroni
cally ill, and yet chronic illness accounts for as much as 70%–80% of healthcare spending, according to Mark McClellan, MPA, MD, PhD, a former CMS administrator and a former FDA commissioner. “Our healthcare system is really designed to focus on acute illness and exacerbations of problems rather than on keeping people healthy in the first place. So that is the fundamental change we need to make, and the benefits of this change would truly be tremendous,” said McClellan.

For example, according to the Centers for Disease Control and Prevention, most of the diabetes and heart disease in this country are preventable through behavioral steps, said McClellan. “If we had been able to hold obesity levels . . . to the same level that they were in 1987, our healthcare costs today would be at least 10% lower,” he said. “That would be $200 billion per year that could go further toward keeping our costs down or helping people get access to quality care.”

Further, McClellan noted that once people become chronically ill, the healthcare system fails to provide adequate treatment and support. “A lot of the responsibility for trying to help people comply with medications and get the support services they need doesn’t even fall within the scope of the way we think about healthcare. It falls on family members and informal caregivers, so we need to rethink all of this.” (See sidebar below.)

Huge obstacles remain

One of the big pieces missing from the current system is the ability to get paid for providing coordination of care, according to Michael O’Dell, MD, chair and director of the family medicine department and residency program at North Mississippi Medical Center in Tupelo. “A lot of us are trying to change. There is clear recognition that our healthcare system is broken, and there is widespread support among providers for change in the system,” he said. “The problem you get into is that you have to see 24 patients a day before you actually start putting money in your own pocket to take home to your family, and when you are running at that kind of pace . . . it is awfully difficult to carve out time [for care coordination].”

In fact, McClellan noted that physicians all across the country are taking steps to implement beneficial reforms such as establishing disease registries, implementing IT into their practices, and forming integrated methods of delivering care or focusing on prevention. However, he added that there are huge obstacles. “All of these things in our current healthcare reimbursement environment typically cause [providers] to lose money,” he said, noting that physicians lose money when they order fewer tests or when they don’t need to see their patients as frequently, and hospitals lose money when they don’t need to treat patients as intensively or when they take steps that reduce the rate of readmissions. “Until we do a better of job of supporting [preventive] care, it is going to be very difficult for providers who want to do the right thing to be able to get the financial support they need to do it.”

There is no question that calling for reform is much easier than making it happen in an environment where multiple stakeholders have their own agendas, but Barrett suggested that the business community may be in the best position to usher in reform. “Systems only change rapidly when the people who have the buying power demand that they change,” he said. “No one has really picked up the issue of how do you get better healthcare, more efficiency, more productivity, and higher quality at the same or lower cost.”

Barrett noted that CMS pays for as much as 50% of the healthcare provided in this country, but added that the agency’s hands are largely tied by the legislative process. Although CMS is conducting numerous pilots and demonstrations related to chronic care delivery, Barrett said the agency cannot move as quickly to implement change as private payers. “I am disappointed in the other half of the payers,” he said. “The business community has been absolutely AWOL in this discussion until recently.”

Caregivers: The second victims of chronic disease

The contributions of informal caregivers toward supporting the chronically ill take a huge toll on the caregivers’ own health and well-being, said Janice Kiecolt-Glaser, PhD, director of the division of health psychology in the department of psychiatry at Ohio State University College of Medicine. Kiecolt-Glaser spoke at “Chronic Care at the Crossroads: Exploring Solutions for Chronic Care Management,” a summit sponsored by the Intel Corporation on July 17 in Washington, DC.

The significant physical and mental repercussions that go along with the caregiving role are not well recognized, said Kiecolt-Glaser, who has performed extensive research into the effect of caregiving. She noted that it further compounds the problem of escalating healthcare costs. “Caregivers suffer enormously. They really are the second victims,” she said. “Caregivers don’t respond to influenza and pneumococcal vaccines as well as noncaregivers, so it means [that] they are going to be at risk for those diseases.”

Similarly, Kiecolt-Glaser noted that wounds don’t heal as rapidly in caregivers as in noncaregivers, and they are at greater risk for a whole host of chronic problems, frailty, and functional decline. “What makes it even worse is that when we study caregivers after they have stopped caregiving, we think they are going to recover,” she said. “But in fact they don’t. It appears that there may be premature aging of the immune system, and this may be because caregivers have lost part of their lives.” Kiecolt-Glaser added that at least one study shows that caregivers have a 63% higher mortality rate than noncaregivers during a four-year period.

Despite the significant sacrifices that caregivers must make, the people who take on these responsibilities typically go without recognition by the healthcare system, said Suzanne Mintz, president of the National Family Caregivers Association and a longtime caregiver herself. “There is pretty much a lack of respect in the system for the role of the family caregiver, when in fact we are very critical to the healthcare team and already save the system close to $3 billion a year by conservative estimates,” she said.

Also important to factor into the equation is the reality that industry loses as much $33 billion per year to lower productivity and employees having to leave the work force to take on a caregiving role, added Mintz. “There are costs to everybody.”