CD&D Washington Editor

ALEXANDRIA, Virginia — Cartoonist and author Scott Adams of "Dilbert" fame is credited with having said that some of the "nutty methods" for predicting the future include reading tarot cards and tea leaves. Or, "you can put well-researched facts into sophisticated computer models more commonly referred to as 'a complete waste of time.'"

Even with these warnings, the heatlhcare predictions continue. And as the second annual Chronic Care Congress began in early June, the predicting was a blend of optimism and despair, with speakers diagnosing and forecasting the cost of healthcare in the world's largest economy.

Ken Thorpe, PhD, a professor of health policy at Emory University (Atlanta), in presenting ideas on the economic impact of chronic diseases, said, "Much of what we spend in healthcare is linked to patients with long-term, chronic conditions," describing "the notion that you're going to solve this problem by dialing up co-pays and deductibles" is not tenable.

Among the panelists was John Lewin, MD, CEO of the American College of Cardiology (ACC; Washington), who highlighted the role of cardiovascular medicine in cutting into the cost of chronic disease care.

"We have had a stunning 29% reduction in morbidity and mortality" over the past couple of decades, but the "costs are also stunning," he said. "The opportunities for continued progress are out there," Lewin said, reminding attendees, "cardiovascular care is 43% of Medicare costs."

Consequently, any progress on heart diseases, which are somewhat related to lifestyle issues, would "make a big difference and possibly slow that growth curve."

He said ACC started developing guidelines, with the American Heart Association (AHA; Dallas), for cardiac-care quality in the late 1980s. "We began doing this a long time ago, and we have dozens of guidelines" and have started on treatment appropriateness guidelines. "The problem is getting that into the point of care," which he said "has proven to be very daunting."

"Only about 54% of the time do we apply evidence-based medicine," Lewin said, saying that some large cardiovascular practices hew to standards of care about 99% of the time. When the exceptional patient shows up, healthcare information technology will allow the cardiologist to explain any departures from the standard of care, he said.

Lewin said that "in 2,400 U.S. hospitals, our registries are operating today" for all kinds of in-patient cardiac procedures. "What we're lacking is the outpatient registry systems," he said, adding that ACC will "roll out an outpatient registry system" next year, which will "change a lot of things."

The ACC chief also tried to explain some of the reluctance among physicians to sign on to reform proposals.

"Part of the reason that people push back is that they think those who are doing the measures have their own conflicts" of interest, he said, but many doctors are also worried about claims data that lack clinical data. Registries for cardiovascular disease that make use of clinical data will make transparency "much more palatable, he said.

"I think the fastest progress will be when we engage the professions" and the medical boards, "and build trust that we're using valid data," Lewin said.

He mentioned the door-to-balloon initiative for treatment of ST-elevated myocardial infarction.

"The science tells us we have 90 minutes" to get a patient into the cath lab to avoid scarring of vital arteries. "If you just measure the performance of the ER team" in isolation, he said, ER doctors perform very well, "but it doesn't matter if it's after 90 minutes ... and the patient didn't benefit."

A year ago, 70% of participating cardiac care centers were not getting to patients within the 90-minute window, but 85% of those centers are getting to the patient in that span. All it required was better information, Lewin said, and "didn't require payment or anything else."

"I think what's lacking is those major practices" have had a 10% reduction in income because of fewer admissions and imaging sessions. "It's hard to sell this across the country and say, 'Let's all do it and get paid 10% less.'"

One of the cost bogeymen, the prevalence of diabetes, has gone up by about 45% since the 1980s, Thorpe said, linked mostly to obesity. He said,"About 75% of spending is linked to patients with chronic health conditions," and most of this and other chronic diseases lands in the lap of the payer.

"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.

He said that the longer-term adverse events of chronic disease "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" thus crying out for a lower-cost approach to behavior and lifestyle modification, Thorpe said.

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 to deal with medical condition "because that's really the only time of day" that it can be dealt with.

Three of every four dollars spent on healthcare are spent on chronic care, half of that on obesity. The problem, he said, is that "the payment and incentive systems aren't there," and "the technology base is not there.".

"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 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."

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 he 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."

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 veterans 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.