Medical Device Daily Washington Editor
ALEXANDRIA, Virginia — Cartoonist and author Scott Adams is credited with having said that some of the "nutty methods" for predicting the future include reading tarot cards and tea leaves. Alternately, "you can put well-researched facts into sophisticated computer models, more commonly referred to as 'a complete waste of time.'"
But that perception, however widespread it might be, doesn't impose any drag at all into the great U.S. healthcare debate. Hence the second annual Chronic Care Congress took flight yesterday with the usual blend of optimism and despair as speakers attempted to diagnose and forecast the cost of healthcare in the world's largest economy.
Ken Thorpe, PhD, a professor of health policy at Emory University (Atlanta), presented a few ideas on the economic impact of chronic diseases and the implication of those costs on healthcare reform, now and in the future.
Thorpe said, "it always seemed to me that a starting point ... is to have a clear understanding of the problem," but "in the political world ... there is not a common understanding of what we're trying to solve." He said "unnecessary discretionary care linked to healthy people" is wrongly blamed for most of inflation, adding that people are not running around having "recreational colonoscopies."
"Much of what we spend in healthcare is linked to patients with long-term, chronic conditions," Thorpe acknowledged, but asserted that "the notion that you're going to solve this problem by dialing up co-pays and deductibles" is not tenable.
One of the cost bogeymen, the prevalence of diabetes, has gone up by about 45% since the 1980s, Thorpe said, most of which is linked to obesity. He also said "[a]bout 75% of spending is linked to patients with chronic health conditions," and most of this and other chronic diseases lands in the lap of one payer.
"Medicare owns most of these patients," Thorpe reminded the audience, but he also described Medicare as "a program that ... is not particularly well equipped to provide the right incentives."
"About 34% of the adult population [in the U.S.] is categorized as clinically obese," Thorpe said, double the rate in the 1980s. Obesity has tripled among minors since 1980, but if obesity levels were the same now as in 1987, healthcare spending would nonetheless only be about 10% less.
"The good news is that much of this can be prevented," as demonstrated by interventions that have trimmed diabetes by more than half in several studies. These were "done in a very expensive manner" that calls for a lower-cost approach to behavior and lifestyle modification, Thorpe said. "We just need to find out how to design these programs" in a way that is cost effective.
Thorpe discussed a recent study of the impact of disease on productivity conducted by the Milken Institute (Santa Monica, California), which concluded that the cost of productivity losses dwarfs related healthcare spending. He said that productivity costs are "four times higher than the expenditure on the medical care side," part of which is engendered by "presenteeism." This is a condition of being at work, but not effectively at work because of using normal business hours "dealing with your medical condition because that's really the only time of day" that it can be dealt with.
Still, the bulk of the problem is in girth. Three of every four dollars spent on healthcare is spent on chronic care, and half of that is spent on obesity and its effects. The problem is that "the payment and incentive systems aren't there," and "the technology base is not there" to deal with this condition, Thorpe said.
"We have to change the way we pay," Thorpe said, adding that Medicare, which he described as "the poster child for this" necessity, must move toward bundled payment and focus more on the role of the primary care physician.
Thorpe pointed out that Medicare "has always been a major innovator and leader" on reimbursement reform, but he implicitly made the case for either a single-payer system or a uniform reimbursement schedule in stating "we cannot have a thousand different approaches by thousands of different payers."
"We have to have some common thinking," he said.
As for the impact of best practices on quality and cost, Thorpe said: "When CBO and others look at these programs" run by Medicare, the resulting numbers are all averages, but Thorpe said that averages are not the correct focus. "You have to target the right patient" in such programs, he said, adding that Medicare demonstrations often enrolled those "who were not the right target population."
"I'm glad they did them," Thorpe said of Medicare demonstrations, but many demonstrations do not tell the story they are purported to tell.
Thorpe said best practices include targeting appropriate patients and fixing incentives, but he said that the data support the case for smarter management of chronic diseases. The "limited evidence says yes" to better chronic care management as a source of cost containment, citing the case of the Veteran's Health system. Thorpe said VA Health "is a closed system," but has nonetheless shown large reductions in bed days for diabetes, COPD and other chronic conditions.
As for wellness, Thorpe said that effective workplace programs are showing returns on investment of up to 5:1, giving the examples of Citibank (New York) and General Motors (Detroit).
Still, such programs must have senior management behind them to work. "It really has to come from the top as a corporate priority," Thorpe said, not just an idea from the human resources office. "There are some great examples of programs that work," but they take time and effort.
Thorpe said many of the underlying issues, such as healthcare information technology, are not particularly ideological, which means "we really can do health reform," and "provide better clinical care to that population." He described himself as "mildly optimistic" that the right discussion can lead to effective reform.