Why chronic care needs to be fixed now

By Valerie J. Nelson

August 3, 1997

To understand how fragmented chronic care is, imagine you are repairing a damaged car. One shop takes care of the rearview mirror, another the tires, another the headlights. Each entity does its job well, but nobody oversees the overall body work.

Translate this into health care, add that a lot of what you need is not covered by insurance, and you have a pretty good picture of chronic care. As Deborah Paone, MHSA, of the National Chronic Care Consortium, said, "It’s not hard to envision why the car doesn’t run real well."

A population that is growing older and a healthcare system that is geared toward acute care are primary reasons that chronic care is a growing problem in this country. Chronic conditions are the leading cause of death; they account for 42 percent of deaths in the United States, according to Chronic Care in America: A 21st Century Challenge, a chartbook published last August by The Robert Wood Johnson Foundation.

"Even if studies have shown there has been a slight decrease in disability among the elderly, there are so many people who are going to be aging in the next century, we really have to recognize this is going to be a big, big problem," said Dorothy Rice, professor emeritus at the University of California, San Francisco who helped research the chartbook.

In 1995, about 99 million people in the United States had chronic conditions, and that number is expected to grow to 150 million by 2030. Right now, the country spends $470 billion a year on the direct costs of medical services for people with chronic conditions. By 2030, those costs are expected to grow to $798 billion, Rice said.

In her opinion, integrating medical and social services is the first step toward dealing with the growing numbers. Many of the services required by the chronically ill—such as having a bathtub rail installed or getting help finding supportive housing—are not covered by insurance.

"There has been an attempt to recognize that frail, older people in particular, really do need more than health care," Rice said. She said some experiments have added social support to HMOs, with great success, but that capitation does not encourage HMOs to use a mix of medical and nonmedical services to treat people with chronic conditions.

"In reality, the managed care industry’s bottom line is to make money. Making money on people’s poor health in particular. So they may not increase the services," Rice said.

Others think managed care plans would profit from properly overseeing chronic care. Bonnie Faherty, PhD, FNP, RN, an associate professor who will join the department of health sciences at California State University, Northridge in August, said HMOs are committed to "catching the teachable moment. Prevention doesn’t equate to dealing with the disease, but there certainly is more education going on" in HMOs.

Members of the consortium are committed to setting up chronic care networks, which are "a person-centered, systems-oriented approach to managing care across time, place, and profession using integration, disability prevention, and managed care financing methods," according to the consortium.

In practical terms, that means looking at problems from lots of angles. Providers would evaluate a patient’s needs at home, for example, and look at the reimbursement system. Typically, financing pays for a procedure rather than a person’s ongoing needs, Paone said, and she thinks that needs to change. In the long term, it would mean setting up an information system to help care providers share data and have a more global view of a patient’s situation.

One change that needs to come about is teaching people how to manage their chronic care, said Rice, who also co-wrote a study on the prevalence and cost of chronic care that appeared last November in the Journal of the American Medical Association. "If they get into the healthcare system, there should be assistance to help them manage their care, whether it’s a healthcare problem, social service problem, or an assistive device," she said.

"So much of what is wrong with us can be managed fairly well with lifestyle changes," Faherty said. "Over and over we demonstrate what can happen with a commitment to lifestyle changes."

The group’s demonstration project on community nursing organizations reflects that philosophy, said Joan Meehan, director of communications for the ANA. The nurse-operated programs, first funded in 1989, deliver chronic care to Medicare beneficiaries in home- and community-based settings under contracts that provide a fixed monthly capitation payment.

Some people think such programs are the wave of the future and the best bet for dealing with the aging baby boomer population. "Fixed costs of chronic care are only going to increase as the population increases and ages," said Catherine Dodd, executive director of the ANA\ California. "Fixed costs’ increase can best be influenced by nursing care in terms of prevention and early screening."