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Rising Rates of Chronic Health Conditions: What Can Be Done?
Paul Ginsburg: Good morning. Im Paul Ginsburg, President of the Center for Studying for Health System Change, an independent, nonpartisan policy research organization funded, in part, by the Robert Wood Johnson Foundation. And I want to thank all you for joining us today, for the first of four HSC conferences on significant health policy topics sponsored by the Pharmaceutical Research and Manufacturers of America, the DMAA, the Care Continuum Alliance, and the American College of Preventative Medicine. Under the sponsorship agreement, HSC and the three groups jointly chose the conference topic, while HSC is solely responsible for organizing and conducting the conference. We will be writing up an issue brief to put out broadly with the highlights of this conference. And in coming months, were planning to hold additional conferences to examine innovative approaches to preventing and managing chronic health conditions and value-based health benefit structures.
The growing prevalence of chronic conditions has added cost to the United States health care system. Prevention and better management of chronic conditions are often cited as ways to improve health outcomes and slow U.S. health care spending growth, or at least generate better value for the $2.1 trillion that we spend annually on health care in the United States. Today, we hope to provide you with an overview of the causes, costs, and consequences of rising rates of chronic conditions, and some possible policy approaches to address what is clearly a significant public health problem. In some respects, Americas rising rates of chronic conditions reflect the huge advances in public health, industrial safety, and medical care over the last century. A hundred years ago, most people didnt live long enough to develop a chronic condition. In 1900, an average Americans life expectancy was 47 years; today its 78 years. A hundred years ago, the top causes of death were infections, such as pneumonia, influenza, tuberculosis, accidents, and child birth.
Today, the leading causes of death are heart disease, cancer, and stroke. While advances in public health and medical care have been spectacular, our health care system is behind the times when it comes to providing early intervention and high-quality care for people with chronic conditions. We have a system that remains focused on providing acute episodes of care. Were pretty good at treating a heart attack, but not so good at preventing and managing the underlying heart disease that leads to that heart attack. Our first panel, Dr. Carolyn Clancy, Director of the Agency for Health Care Research and Quality, and Dr. Eric Finkelstein, Health Economist and Director of Public Health Economics Program at RTI International, are going to give us an overview of chronic conditions and some insights into how we got where we are and what the consequences of rising rates of chronic conditions mean for patients in the health care system.
And Dr. Finkelstein is going to help us understand how rising rates of obesity are related to our economic prosperity. Dr. Clancy.
Carolyn Clancy: Good morning, everyone, and thank you, Paul, that was a lovely backdrop for a very huge, huge set of issues. And if theres one point that Paul just made that I would underscore, it is that this is a consequence of success in treating acute conditions. So on some level we might say, well, this is a good problem to have. That would be the good news. The slightly less good news is, our health care system is not really set up for that, and on some days it feels like for every two steps forward we make, we take one and a half backward, because our mindset is so dominated by acute conditions, or what my residents used to call stamping out disease, they werent always joking.
So its really a privilege to be here and also a privilege to be here with Dr. Finkelstein. So Im just going to paint a very broad brush in order to set the stage for subsequent discussions about what do we do next.
If you think about t.v. shows, right, it is never about chronic conditions, you know. It would not be, how would I say, a story line for House or ER or anything else, even though, you know, that someone actually now is managing their diabetes effectively.
I think this is a spectacular lack of imagination on the part of screenwriters myself, but the bottom line is, what captivates our imagination and so forth is all of this drama, and in a very funny way, that frames how we think about health care in many different ways. And yet more people die every year from heart disease than AIDS, tuberculosis, and malaria combined. Thats not to say those problems arent important, of course, but there are big, big issues. And as Paul also noted, as we get better and better at acute intervention, to the point where its actually hard to measure mortality rates in many institutions and the complication rates keep going down. However, our luck in collaborating with patients to get them to adhere to recommended medications after theyre discharged for these procedures, as far as I can tell hasnt budged at all, and its pretty dismal.
So chronic diseases now account for 60 percent of global deaths and will account for about 75 percent of all deaths by 2020. And developing and transitional countries are catching right up to developed nations in this regard.
So from the statistical brief, which is in your folder, from the Medical Expenditure Panel survey, my colleagues were able to demonstrate that in 2005, about 60 percent of the U.S. population over 18 had at least one chronic condition, and $3 of every $4 spent on prescriptions was for treatment of chronic conditions. And Im sure a lot of you were quite struck by the story in the New York Times the other day about how were now adding children to those ranks; the statistical brief does not address that issue specifically. Nearly four in ten Americans between 18 and 34 had one chronic condition, as did nine out of every ten aged 65 and older. And for those in the Medicare program, chronic conditions is where we spend the most money and provide the worst care.
A relatively small proportion of folks, and I would never use an exact cite in front of Paul, who could be much more precise about it than I could, but the small proportion of folks who account for a very, very large proportion of our expenditures are people with multiple chronic illnesses.
Now, interestingly, as this population becomes more diverse, we end up with a sort of two-fold challenge; number one, many of these chronic conditions, the leading chronic conditions, are more common in people of either lower socioeconomic status and/or people who are members of racial and ethnic minorities, a phrase I have to use with some care because a number of communities will soon be majority minority.
But the conditions are not only more prevalent there, but we also do a worse job for those patients in terms of quality of care. So what Im showing you here is a picture of an article in JAMA published about a year and a half ago by Johnny Ayanian and his colleagues at Harvard, and what they did was to actually look at black/white differences for patients enrolled in Medicare Advantage plans. And they had found two things as a result of this in a previously published study; number one, public reporting and transparency on quality has actually really focused attention, so the disparities are minimal and not significant between blacks and whites for those items that are completely under the control of providers in the exam room, ordering the right tests and so forth. For those of you who are thinking this sounds pretty basic, youd be right, but nonetheless, we werent doing so well before, so things are moving along.
When you start looking, as this paper did, at actual control of hypertension, control of LDL cholesterol, the proportion of folks who are - whose diabetes is not under good control, were not seeing any narrowing and disparities at all.
Very, very slow improvements, but yet the overall rates across all people are still not that great, somewhere in the ballpark of 60 percent for optimal control of diabetes, hard to believe thats the Everest of our ambitions. But if you think about it, this is where the patients role in self-management comes in, and I think a real opportunity for clinical care delivery to link in some new kind of imaginative way with community resources, public health and so forth.
So this slide just shows that in 2004, 26 percent of all Americans had two or more chronic conditions, and clearly these numbers keep increasing. Nine of the top ten highest cost conditions are chronic in nature. The only one that is not a chronic condition, at least not by our current definitions, would be trauma.
The rest you can see here, and I know that youll be hearing more about how some of these conditions cluster in individuals, because the individuals whove got multiple chronic conditions are the people where we have a really unique challenge, and the opposite side of that would be to say we have an opportunity to improve care.
If you look at overall spending, 85 percent of health care spending is for people with chronic conditions. And we also know from the Milken Institute, and I notice the brief is also in your folders today, that 40.2 million cases of chronic conditions can be avoided, and $1.1 trillion, wow, can be saved by 2023 by making reasonable improvements in preventing and managing chronic diseases. And you can see for each of the conditions listed here the number of cases that wed expect in 2023 and the potential number that are averted. So this begins to put boundaries on the scale of the opportunity before us.
Now, Ive made it sound like, well, weve got a bunch of straight forward things to do and we just need to pull up our socks and figure out how to do them. The reality is, most of our scientific evidence base actually derives from one condition at a time. So weve got enormous depth in what to do and the effectiveness of different treatments and diagnostic strategies for cardiovascular disease.
For example, weve got probably not quite that deep, but a lot of information on how to manage diabetes or how to manage some mental health conditions and so forth. Where our evidence base is pretty thin is how to manage effectively people whove got several of these chronic illnesses, particularly people for whom one of the chronic illnesses is a mental health disorder.
Weve been describing with great detail, as have many others for a number of years, that all things being equal, if you have a heart attack and youre depressed, you do worse, controlling for everything else then if you simply have a heart attack, and the list goes on and on for studies like that. The next frontier is clearly going to be to figure out how do we treat that combination effectively and how do we help patients deal with that.
When youre looking at people with multiple conditions, youve not only got interactions between illnesses and between treatments, youve got people on multiple medications, multiple providers -- the Center for Studying Health System Change I think has shown this in a very compelling, if scary way, just how many providers some patients are seeing, so many that its really hard to imagine that theres a common script across this array of clinicians.
And sometimes its even attention between therapeutic goals. If you are dying of cancer, maybe we dont want you to have a hemoglobin A1C of seven would be an extreme example. But when you, you know, struggle with which diabetes medication is right for someone who also has cardiovascular risk factors, you know, these issues become very, very real for clinicians. Just a couple of words on some things that AHRQ is doing in this area right now. This has been a big focus for us and will continue to be so, both in the work we do evaluating applications of health IT, to improve safety and quality, as well as in the safety arena itself. Every year we report to the Congress on quality and disparities in health care, and what weve been finding for the past several years is a pretty profound set of disparities for older Hispanics.
So for the past year weve been working very closely with the area agencies on aging, through the Administration on Aging, as a way to actually get into communities with a high penetration of Hispanic elders, to try to provide evidence- based tools and peer-to-peer learning, to keep those folks as healthy as possible.
There are eight communities shown here. I dont think the list here would surprise anyone. And the team has developed community partnerships to target health disparities among Hispanic elders. What this has involved for us is taking data from the disparities report and bringing it down to the local level so they actually know and can literally map what are the neighborhoods that need the most attention. And I think its going to be that kind of series of partners, and frankly, incentives for those partnerships, which is going to help us get to a better place managing chronic illness. We have funded some work this past year, I mentioned, in the use of health IT. This is just one example here shown for shared medication management and decision support for clinicians working in rural areas.
Medication management pops up on almost everyones list of priorities to improve in health care, because again, if youre a patient seeing six doctors, the likelihood, in my clinical experience, that not everyone knows all the medications youre on is close to 100 percent. That is not a scientific observation, by the way.
Ultimately, weve got to build a health care system that is information rich and patient-centered, and notice how that rolled right off my tongue. That is really where health IT is going to make a huge difference.
One other resource in terms of patient centered that I just wanted to mention to you, and we didnt have a chance to share it today, we very recently put up on our Web site an evaluation done by a team at RAND of patient self-management programs. This was work originally developed by Kate Lorig and folks at Stanford, and since then has led to many other modifications and so forth, very much a work in progress. But if theres one thing weve learned from these programs is, this is not all about clinicians, this is very much about how patients live with a disease and manage it. And its probably not so much about knowledge as it is about motivation. So Im just finishing up here with an article or a commentary that was recently in the Archives of Internal Medicine, and this is more, again, just to give you a sense of the challenge before us.
I had the privilege of offering a commentary on a paper that came from Harvard Vanguard. Now, Harvard Vanguard is the medical group thats left from the Harvard Community Health Plan, and on paper they got it all right, right. They work in teams, theyve got incentives to do better, theyve got electronic medical records, theyve had them for a really long time, they have clinical decision support and so forth, and yet what this article showed was that not only did they have disparities in management of diabetes and associated cardiac risk factors, but that those disparities were very clear and significant at the level of individual docs.
Now, the good news is, theyre taking these findings and now trying to give docs feedback and figure out what do we do next. But what else has struck me was, notwithstanding all those structural resources that we think of as so critical, their results actually arent very much different than the mean for plans reporting through HEDIS. And again, this brings up the, how do we do much, much better than having roughly 60 percent of people with diabetes effectively managed. Yes, there are some that we dont want to actually be that aggressive with, but its not 40 percent. And to do that, I think were going to have to stretch our brains much more about what are the boundaries of clinical care, how do we provide incentives to clinicians, to systems, and ultimately even to patients to do a much, much better job, because, clearly, their health and the future of our health care system depends on it.
So I will simply end with a brief public service announcement. If youre interested in this stuff, our annual meeting is in September and its free. Thank you for your attention.
Paul Ginsburg: Thank you; Eric.
Eric Finkelstein: I do want to make one comment somewhat related to Dr. Clancys comments. We actually have a paper coming out based on data from CDCs program, where they bring women in and they screen them for heart disease risk factors, cholesterol, diabetes, high blood pressure, and, in fact, what this paper shows is that half the women who come in and are identified with diabetes or high blood pressure or high cholesterol, when they come in a year later, they will - half the women will say theyve never been told that they had these conditions, yet we know from our base line data that theyve come in, that theyve been screened, theyve been diagnosed, and that theyve been presented with information about these conditions and treatment options. Twelve months later they claim theyve never been made aware of it.
And I think thats critically important in trying to understand why theres a disparity between what the physicians are saying and what the patients are saying.
So let me move on to my topic. I just want to talk fairly briefly about obesity, clearly a risk factor for nearly all of the chronic diseases that Dr. Clancy mentioned, and, in fact, as you all are well aware, a growing epidemic in this population for both youth and adults. And what I want to do essentially is talk about obesity as an economic issue and set the stage for how economic factors are not only responsible for rising rates of obesity, but that these rising rates of obesity have significant economic costs on businesses and on government, and then ultimately tell the story of how its going to be economics or a changing economy thats going to stem the tide in rising rates of obesity.
Im going to move relatively quickly because I know we dont have a lot of time and I know that we want to have an opportunity for some questions. So let me just present this slide here, which basically shows rising rates of obesity over the last couple of decades from the NHANES [National Health and Nutrition Examination Survey] data.
Now, one thing you cant see from the slide, but I do want to make it clear, is that rising rates of obesity have increased among all subsets of the population. But, in fact, I think people might be surprised to know that its actually been Higher-income groups, not lower-income groups, who have seen rates of obesity rise fastest, and I think thats an important point because I think theres a general misconception that obesity is more of a problem among lower-income groups, and my point is, it certainly is a problem among lower-income groups, but, in fact, its a problem among all income groups. And, in fact, once you separate out race and gender, at least for men, for example, theres almost no SES grading to obesity. Rich, African American men have about the same obesity rates as low-income African American men, same with Hispanics, same with Whites.
With women, there is an SES trend, but its actually very small compared to the huge racial gaps in obesity rates, and so I wanted to just make that point clear, and we can talk about some of the implications of that hopefully when we move forward.
Just a quick story that I think really sets the stage for what Im trying to sell when I talk about the economics of obesity. Mauritania, as you may know, is an African country, and in fact, the history of Mauritania is that, well, part of it at least, is that if a young girl wanted to get a great husband in Mauritania, basically what she had to do was get fat, super fat, the more fat she had, the better the husband.
And so for generations, moms and grandmothers would force feed their daughters and fatten them up in efforts to get them a good husband. It went on for generations, but, in fact, about 15 years or so, this actually stopped, or at least has gone down considerably. And the reason was not any public health campaigns aimed at changing behavior, although those were going on; what happened was, there was a famine in Mauritania and the price of food sky rocketed, and mothers and grandmothers just couldnt afford to feed themselves, let alone over feed their daughters, and so this practice really died away.
And so the moral of the story is basically that in the U.S., here where cultural norms are for thinness, certainly at least for Caucasian or Caucasian women more so, were seeing exactly the opposite phenomena taking place. Cultural norms are for thinness, yet we see rising rates of obesity.
And the argument that Ill make here is, its exactly the opposite of whats happened in Mauritania; food prices, as well as prices for other sorts of labor- saving technologies and other things have gone down, so were seeing more food consumption and less physical activity, economic argument.
And let me formalize that argument by talking about some of the data associated with food consumption and caloric expenditure. If you look at the NHANES data, what you find is that food consumption or caloric consumption has certainly increased dramatically over the past few decades. So consistent with the story of, you know, more food consumption, rising rates of obesity. And the argument that Im selling is, the increase in food consumption is a direct result of a decrease in food prices, both the monetary price of food, as well as the opportunity or acquisition cost of getting that food into your mouths.
And, in fact, theres some data that I presented on this slide thats probably easier to see here which looks at the trends in food prices, up until, of course, the last two years, where weve seen a big change in food prices, but Ill return to that point in a second.
If you look at the slide here, basically this line here is the general CPI of food. Things below the line have gotten relatively less expensive; things above the line have gotten relatively more expensive. And if you look at the things above the line, what you see, its fresh fruits and vegetables, fish and seafood, fruits and vegetables, those things have been getting relatively more expensive relative to things that have lots of added sugars and added fats, and so its not surprising that were consuming those things in greater quantities. And, in fact, right here you can see the relative price of food, at least until about 2005, actually had dropped fairly rapidly compared to non-food items. So again, its an economic argument that suggests as food prices go down, food consumption goes up.
And I can tell a similar story about opportunity or acquisition cost. Certainly fast food prevalence has increased dramatically, restaurant food has increased, theres been great technology in freeze drying and prepared and pre-packaging.
But I think a great example of all of this is the microwave oven, which clearly makes it very easy to consume lots of tasty and affordable food very easily. And, in fact, if you look at the microwave oven, only about 8 percent of homes had them in 1978, and, in fact, today, almost every home in the country has one, and thats just one example, but it certainly points to the idea that its just cheaper and easier to consume food today, so not surprisingly, we consume more food.
Let me just flip to the caloric expenditure side of things. And Ill talk first about the leisure side of things, and Ill make the argument that basically we would expect to see less leisure-time physical activity because its now competing against better technologies that are essentially crowding it out. And I point to examples like the Internet, computer games, DVDs. These things just werent available, and so we have more to compete against, and so were seeing leisure-time physical activity getting squeezed out.
And again, I just point to cable TVs as I think a pretty good example. Seven percent of homes had them, you know, a few decades back, and today about three- quarters of homes have them. Internet access is another one; actually, that number needs to be updated, its much higher now.
But the point is, in our leisure time, where we used to engage in physical activity, its now essentially being competed against by technology that just wasnt available, and so were seeing it crowded out.
In fact, those of you like myself who have kids at home certainly know what Im talking about when youre trying to push these kids off the technologies and get them to go outside and engage in physical activity. But the same story goes for the non-leisure time, what I call accidental exercise, the exercise that people used to get throughout the work day. Today, weve mechanized just about every occupation where youd have to think pretty hard to find an occupation that hasnt been mechanized to the extent that you get almost no physical activity at all. And so I make the point that accidental exercise is almost non-existent.
And again, another economic argument, we certainly could reengineer physical activity back into our work day, but the reality is, wed probably get lower wages as a result because wed be less productive, wed produce less, and so goods might be more expensive, and really, Im not convinced we would want that, and Ill return to that point in a couple slides.
There is a great paper by Lakdawalla and Phillipson that shows that if you work in a sedentary occupation your whole life, youre going to weigh about 25 pounds more than if you worked in an occupation that had a lot of fitness demands. And so, clearly, the changing economy, the workplace economy, has also played a role in helping us gain some weight.
And I do want to point out, I actually tell the story, I ran a marathon a couple years ago, and I tracked my steps on a pedometer for the four months until I got the 53,000 on the day of the marathon, and, in fact, over that four month period, I averaged only about 10,700 steps for day, which isnt much more than some of the recommendations out there for physical activity. And the reality is, if I wasnt out doing my three or four mile jogs, I was sitting on the computer doing pretty much nothing.
And so I make that point only to say that essentially if you want to get your five miles per day or get the 10,000 steps recommendation, you pretty much need to go out and train for a marathon, and the reality is, thats a pretty tall task.
One other cause of rising rates of obesity that I think is overlooked, but also critically important, and this is what I call moral hazard. In economics, moral hazard is the idea that once youre insured against some type of bad outcome, say if you have car insurance, you may be less likely to lock your doors or less likely to drive carefully, and so the reason is because you know that you have some third party whos going to cover the cost of a poor event or a bad outcome. And so with respect to obesity, I try to make the argument in the book that essentially the health costs of obesity, not that obesity isnt bad for your health, but that its not as bad for your health as it used to be, and so if the health consequences of obesity have gone down, then a rational agent or some individual might say, well, I dont need to worry about being obese as much as I might have in years past, and that might partly explain, as well, why we see rising rates of obesity.
And I point to statins and all sorts of new products and services that are just readily available today that can help the obese individual better manage the adverse health effects, and so they may be less worried about their excess weight.
And, in fact, theres a great article by colleagues at CDC who actually show that todays obese population has a better cardiovascular disease profile than normal weight individuals did, not the obese individuals, but the normal weight individuals did several decades back. And, of course, thats partly due to the statins and all these new technologies that just werent available. And Im not talking about technologies to treat obesity, Im talking about technologies to help manage all these conditions that obesity promotes. And so really, Im just trying to point out that its an economic environment or the changing economy thats lowered the cost of food consumption, price and non-price, raised the cost of physical activity in terms of the opportunity cost, as well as being physically active on the job, and thats essentially lowered the health cost of being obese, and so these three factors have really combined to create an environment where we would expect to see rising rates of obesity, which is exactly what weve seen.
But I do want to make the argument that these changes in the economy are not on accident, right. Consumers are certainly demanding lower cost products and services, we like technology, we like health care that can cure us when we get sick, and so these changes, in effect, reflect consumer preferences, and so while obesity in and of itself is bad, we have to ask ourselves, although we may be fatter, are we actually worse off, right.
And I think we need to ask that question, because when we start thinking about solutions, these solutions arent going to be done in a vacuum, theyre going to impact all of these factors, and we need to understand what individuals are actually willingly going to do to change their behavior, okay, and Ill return to that point in one second. And so the point of the argument here is that, you know, with the changing environment, its not that obesity is not bad for your health, but that the behaviors required to get people to weigh less are just becoming increasingly costly, and so what economists call a utility maximizing individual or somebody whos making good choices may actually make good choices that lead to excess weight.
And, in fact, in the book I talk a lot about my obese Uncle Al, who happens to be a very smart, very successful, very wealthy attorney whos obese because he spent his adult life working in the law firm and wining and dining clients, whereas other individuals have spent their time dining and exercising, and the reality is, for my Uncle Al, its hard for me to argue that his choices were not rational or not well informed, theyre just different choices than he might have made a few decades back, and perhaps different choices than the public health community would like, but its very difficult for me to see what we could do or say to get Uncle Al to change his behavior. And, in fact, even more importantly, I think we need to ask ourselves why we even want to do that. And Im not saying we dont, but Im saying that we need to ask these questions before we start trying to get him to change his behavior.
So just to make one point as I conclude, essentially, if youre going to try to get people to change behavior, I would make the argument that you need to change the environment and make it cheaper and easier to engage in those behaviors that are health promoting and more expensive to engage in those behaviors that are obesity promoting.
And so I talk about interventions that change cost and benefits are those most likely to be successful. I dont think information campaigns are likely to have much of an impact, because I think people either do know or could know that these things are bad for them and that information is maybe part of the story, but in and of itself is not going to be enough to significantly change behavior in an environment thats pushing us in the wrong direction.
I talk about incentives; we actually have a paper that we published that showed for $7 a pound, at least for a little while, you can get people to lose some weight. And Im not saying thats a cure all to obesity, but it certainly suggests that even small incentives matter and can be potentially effective, certainly more effective potentially if combined with some environmental and other changed factors that make it easier to engage in healthy behaviors.
So just to wrap up, in my opinion, obesity is really a side effect of our own success, and that given this changing environment, we would expect to see people increase their weight because of the fact that its just more expensive on many levels to be thin.
When it comes to government, I want to make two points, one is, and its not really on the slide, but many in government have used the high cost of obesity to justify government interventions.
Obesity is clearly costly on many levels. But if youre going to use the high cost of obesity to justify public money on government interventions, then by definition, those interventions must be cost saving, otherwise youre going to increase the tax burden even more, right. So if you want to use that argument, then you can only justify cost saving interventions, and the reality is, publicly funded cost saving interventions just dont exist. In fact, I dont think any cost saving interventions for obesity that Ive seen, maybe bariatric surgery, but I think thats pretty debatable, as well. And so I think that we need to be careful when we talk about the high cost of obesity as a rationale for public obesity intervention efforts.
One other point, I think the governments role in obesity should be not really to be in the obesity prevention business, per se, but really to look at some past policies that probably helped promote obesity rates, and Ill point to some of our agricultural subsidy policies, for example, even zoning policies that essentially encourage people to use automobile transportation as opposed to other forms of transportation. Even some of the ways we subsidize health insurance I think promote treatment over prevention.
And so the government can really look at these policies and say, these may have made a lot of sense at the time, but in a world where two of three individuals are overweight and obese, do these policies still make sense? And I think that would be very helpful for the government to engage in that kind of thinking process. And then again, I think that incentives on many levels are going to be part of the solution, but, in fact, I think only part of the solution. I also think that although technology is certainly part of what got us into this current epidemic of obesity rates, technology is also going to be part of the solution.
And I think, you know, we can talk obesity drugs, for example, and you know, the reality is, public health folks may not like that as an obesity solution, but my Uncle Al probably would and I suspect would pay lots of money for it.
But I dont just mean obesity drugs or procedures, Im talking about technologies that may reengineer physical activity into our work and entertainment like, like the Wii video game system, for example, or lots of new technologies that we might not even have thought about yet that certainly are, I suspect, going to come around the corner, because although, you know, obesity rates are high, theres a huge demand for products and services to help people lead thinner and healthier lives, and I think the private sector will respond. Ill stop there. Thank you very much.
Paul Ginsburg: Id like to thank you both for some terrific presentations. I have a couple of questions; each of you may have some questions or thoughts. And then Id like the audience to get ready for their questions. Were going to have a mix of question cards and people coming up to the microphones.
So let me begin with a question for Carolyn Clancy. You know, if you think of the pretty striking data you presented on proportions of people with chronic diseases and the portion of health care costs they account for, figuring that the initial audience at least for data like this are opinion leaders, every once in a while I get into a conversation with an opinion leader that says, well, you know, look at me, I have two chronic conditions, my blood pressure is too high and my cholesterol is too high, I control them both. How many people like me are in those statistics or are we a minority of it? And I dont know if your staff has done any digging into that.
Carolyn Clancy: We have done some examination of that. And I mean the other way to go about this is to actually look at the concentration of expenditures, which is where I didnt want to get too precise because I know this is an area where youve done a lot of work, as well.
Paul Ginsburg: Im sure youll be right.
Carolyn Clancy: So I will clarify using my medical training. You know, in medical school you learn that 20 percent of people get 80 percent of conditions, and it turns out that the concentration of expenditures kind of looks a little bit like that, as well, so I want to say five or six years ago it was 20 percent of people incurred about 72 percent of our health care expenditures.
What that means, that has huge implications for many cost-containment strategies. But the vast majority of those folks have multiple chronic illnesses. So, yes, there are healthy people, and yes, for those of you who are JAMA readers, you may have seen a little sardonic column a few weeks ago that talked about how to make P for P work for you.
This is from disgruntled doctors who think the whole thing needs rethinking, which basically said, you know, you can basically over read and over diagnose and pump up the denominator and then your panel will look better. But I dont - I mean I think Eric has got a terrific point, and it would be great to dissect that, how many people are very well maintained now and the medications that we have. But by and large, when you look at how we got to pretty substantial reductions in mortality from heart disease, clearly hypertension was a huge, huge part of that, and the rest has been sort of secondary prevention, you know, making sure people get beta blockers and so forth. But I think theres a lot of opportunity to do more of that kind of modeling, as well.
Paul Ginsburg: In fact, maybe something that would be useful for future surveys is questions that would help you distinguish - well, actually this would be hard-- I guess youd need physical examination between people who have controlled hypertension and people who have uncontrolled hypertension.
And a question for Eric Finkelstein; you know, a lot of the things you said is how, you know, broad economic forces are important determinants of obesity, you know, particularly the price of food. But then you mentioned that socio-economically, that within say an ethnic group, very little variation, and how do you reconcile the two?
Eric Finkelstein: Well, I think the reality is, weve all - all consumers have seen the same price drop, and so its not that prices of food have gone down for poor people so poor people are gaining weight, weve all seen price decreases, and so what Im trying to say is that broad changes in the economy have impacted all of us, and so weve all equally seen this rising rate of obesity.
Now, I think for wealthier populations, they may have actually seen a rates rise a little bit faster, because there was a disparity three or four decades back, but that may be because they have more resources that they can spend on, you know, tasty food and sedentary entertainment.
Paul Ginsburg: Yes; because I would have thought that if the food prices are falling for everyone, that youd have a larger response if youre low income to that.
Eric Finkelstein: Thats actually a good question. I mean one of the questions that Ive sort of been curious about is, people tend to assume that low-income consumers eat more fast food, for example, or drink more Coke, Im not sure thats true, and in fact, thats an empirical question.
We actually just got a grant to take a look at this question. I mean I suspect low-income consumers probably drink more, you know, lower-priced Coke, and rich people maybe drink more Coke and Pepsi, but who consumes more calories from carbonated beverages, Im not sure. I mean rich people have more money to spend on liter goods, and they like Coke, maybe they drink more Coke. And Im not trying to say Coke is whats causing obesity, but you know, you can extend that argument to lots of products.
Paul Ginsburg: Sure, thanks. And you also made a point, which I think is very wise, that there probably are few opportunities for public policy addressing obesity to actually save money for government, and is there much discussion among people you work with about this issue that if, in fact, government succeeded in reducing obesity, that since most public spending for health care is focused on elderly people, that actually that might - that success might increase spending because there would be more people enrolled in Medicare more years to collect those benefits?
Eric Finkelstein: Well, you know, this is a funny argument, but, in fact, this was the argument made for smoking. And, in fact, people have said, well, if you really want to reduce the burden of smoking, you should subsidize cigarettes, because you get all these people to smoke up, they pay a lot of taxes, then they die before they collect on their social security argument. And, in fact, people have tried to make similar arguments for obesity, but the reality is, for obesity it doesnt hold because people get these chronic conditions at fairly young ages, and really, the mortality impact for obesity is pretty small.
And, in fact, Kathryn Feegle at CDC has published a paper that shows that it may be non-existent until you hit BMIs in the mid 30s or higher. And, in fact, we have a paper that came out a couple months ago in Obesity that shows the life-time costs of obesity is actually greater. So that sort of cost saving argument doesnt hold.
But I think the broader question is, is the extent to which its appropriate to use cost of obesity as a justification for these public sector interventions, and I think we really need to be careful how we frame that argument.
Paul Ginsburg: Good; now its time for you, and do you want to start, sir? And actually, if you people could just line up at the microphones, because Id like to get a recording. And please pass your cards into the aisles of those that prefer the question cards. Yes, why dont you go ahead first.
SPEAKER: Hi, Im wondering, what should employers be doing in their disease management programs and wellness programs to address the chronic - the co-morbid conditions, you know, the person with two or three? The sense that I get right now is that, you know, they have cost saving measures, but theyre, you know, you might get put into the program for cholesterol, and you might get put into the program for hypertension, but maybe theyre not integrated.
Paul Ginsburg: Yeah; actually, one thing I was going to say is that a speaker on our next panel is the ideal one for that, but if either speakers on this panel want to respond, go ahead.
Carolyn Clancy: So let me just say that disease management programs I think still represent a fertile area for more research, because it gets very hard for us to identify who are the people most likely to benefit, how to address the challenges of people with multiple conditions when weve got programs that address one at a time and so forth.
I will say Ive had the opportunity recently to hear about some employers who are doing some pretty innovative work for some of their sicker employees with several chronic illnesses, which is pretty exciting; Boeing is among them and so forth. And having had a discussion with employers about this last week at our Advisory Council meeting, what came out of the discussion was a number of employers saying, you know, Im realizing now that we get the fact that if we make people pay out of pocket, for example, for medications to manage chronic illness or for preventive care, they may not do it, so were actually providing some support for that, but we dont actually know how to do that, what the right amount is and so on and so forth.
And I was thrilled to hear about that because it seemed to me an opportunity for empirical information to literally shape that kind of policy.
Paul Ginsburg: Yes.
Stephen Forstenzer: I have a comment and/or question, depends on the way you look at it. My name is Steve Forstenzer, Im with the Maryland Health Care Commission. The issue that were talking about on the economic impact of chronic conditions aint new. I was doing a research project in the 60s, when a lot of people in here werent born yet, and discovered that essentially were talking about the same ratio. It was about 70 percent of the health care dollar in the early 1960s was spent on chronic illness. And no matter how many voices were yelling in the wilderness, no one was paying very much attention.
Im glad to see people are now on it, but I wonder how come it exploded as an interest other the fact that its costing more money that it used to in terms of real dollars.
And the other point I have for Dr. Finkelstein is, were dealing with sociology, and what do you think the impact was on having phys ed cut out of virtually every school system in the United States because it cost too much money to have gym?
There were generations who learned that exercise was part of your life, because like it or not, you started in second grade.
Carolyn Clancy: I think the why now question is quite interesting, and Im not sure I know all the answers. I think the work of Ed Wagner and others trying to be as explicit as possible about what health care could do to address those issues. I think theres also been an accumulating, how would I say, critical mass of information and a sense of how important this is as life expectancy has continued to increase. When you look at the 20th century, as Paul pointed out, that is huge, and therefore, the number of people were talking about and the magnitude is so much larger. Beyond that, I dont know, that might need to be the subject of another session.
Paul Ginsburg: Actually, one thought I have is, the combination of medical care on the one hand, when done well, can really be much more effective when dealing with chronic disease than in the past, but unfortunately, the cutting edge of medicine is hard to do well, and which gets into all of our issues about the delivery of care. Do you want to take a crack at the gym?
Eric Finkelstein: Yeah; I wasnt alive, so I really probably shouldnt say. I dont know what was going on in 1960 - although I will say health care as a percent of GDP has more than doubled, and I think thats probably been a significant factor on why this is at the forefront for employers and governments.
With respect to your comment about physical education, I think you could make an equally important statement about what were feeding our kids in school, in effect, a host of things were doing with kids. And, in fact, I really have come to the conclusion that I think for the governments role on obesity, the government has a role for consumer protection of kids, for sure, and we force kids to go to school, we dont let them drink, we dont let them smoke, we have a host of regulation that we think is appropriate for kids and not appropriate for adults.
So when kids become old enough to make informed choices, they may grow up and become overweight or obese adults like my Uncle Al, and my feeling is, that might be okay, but while theyre young and before they can make rational choices, we need to set them off on the right path.
And so I think that, you know, governments role should be to make sure that these kids get physical activity and get a healthy meal at school while they can, and then set them on the right path, and then when they become adults and decide to make choices, some of which may be obesity promoting, those are their choices and we should live with it, but while theyre young, thats where the government should make, you know, the strongest case for obesity prevention efforts.
Paul Ginsburg: Okay. Ive got a question on a card for Eric. And this question is referring to the role of the sedentary jobs, and the questioner asks, how could an office job incorporate accidental physical activity, and how does policy address activity in the workplace?
Eric Finkelstein: I think thats a pretty tough question. In fact, Dr. Goetzel may talk a little bit more about that in the next session. I think the reality is, its going to be pretty hard for most occupations. I mean Ive heard about the treadmill work station, but I suspect thats unlikely to be at most desks anytime soon.
There are some things, and Ill let Dr. Goetzel talk more to these, but there are certainly environmental change, things going on in the work site but I think were not going to reengineer the work site to a place where youre going to be sweating off the pounds.
It will essentially potentially make it easier and cheaper to engage in some level of activity. In fact, you know, for example, I often times will have meetings where well go for a walk around the campus, because my company just put in a walking trail, I mean things like that that arent going to change obesity rates from, you know, 33 percent down to 3 percent, but they might change them from 33 percent to 32 percent, and, you know, maybe those marginal changes over a long enough period of time could have some impact.
Carolyn Poplin: Hi, Im Dr. Carolyn Poplin, Im a general internist, and I came in late, so forgive me if youve already covered this. But I talk about diet and exercise until Im blue in the face. I was born in 1947. When we were growing up, we walked to school, not because it was good for us, but because it was the only way to get there, lots of people did manual labor, my mother stayed home and cooked, so there was very little fast food available.
I think this has a lot more to do with the government restructuring our society in ways where the default, so to speak, will be walking, more public transportation, less parking, more places to - sidewalks and places to walk to. I mean these are things that can only be done by government.
Theres also the Agriculture Department which has put out - which has changed a food pyramid, so its a vertically striped thing, it kind of defeats the whole message, and its a function of the influence of the food industry, and thats easy to change and should be changed right away. But theres a lot thats not medical. When you have to take time out of your day to exercise, instead of it being an unavoidable part of your day, then people dont exercise - some people exercise because they want to, but most people exercise because they have no choice.
Paul Ginsburg: Thank you. Anyone want to comment on that?
Carolyn Clancy: I guess the only comment Id make is to say thank you, but also that it strikes me that when Eric talks about government policies, youre talking about cross department kinds of strategies. This wont be because HHS or any one single department does that. I dont think our track record is all that terrific in terms of sustained activity across cabinet departments, which doesnt mean that it couldnt be, were certainly seeing that in some other developed countries now.
Caroline Poplin: I mean think about road building, they say the place where the BMI is lowest is in Manhattan.
Paul Ginsburg: Yes, sir.
David Rabin: David Rabin, Georgetown; Dr. Clancy, what do we know about chronic disease control under other health systems of other nations, and what can you - if there are differences and better control - what characteristics of those systems are ones which are associated with better control of chronic disease?
Carolyn Clancy: You know, the Commonwealth Fund has done a number of surveys of multiple developed nations, either five or seven countries, and will have another one coming out this fall as I understand it, and theyve been highly instructive.
In some cases, the U.S. doesnt look as great in terms of the proportion of docs who have electronic health records, which we think could be very helpful here and so forth. But I have to tell you, Im really much more struck by how similar these countries look. So I do see this as kind of a global challenge.
Melanie Fagen: Melanie Fagen with the American Medical Group Association, and this is for Dr. Finkelstein. You mentioned agricultural subsidies and I just wanted to ask about your opinion on the recent farm bill that passed and the DOD fresh fruit and vegetable program. Do you think this is something thats effective in schools, do you think well see a difference in obesity? And in - with subsidies, which ones would you reduce and which would you increase, and could you touch on corn?
Eric Finkelstein: Yeah, a bunch of questions, and I think you probably outlined a research agenda that could keep us going for quite a while. I think, first off, obesity is so multi-faceted and there are so many influences that impact how much kids eat and exercise and all those factors, so I think we first probably need to step back and look at how do changes to the school food environment, for example, impact kids caloric consumption, let alone obesity rates and I think we need to first really take a hard look at that.
And I think the evidence base for all these things is really weak, and so we really need to do some serious research and figure out where are the leverage points to really influence kids and what impact will these things really have.
In fact, just as an example, theres a study that shows that kids gain more weight in the summer than they do during the school year, which if thats true, it says something about how they maybe are eating healthier at school than they are at home or getting more physical activity. So lots of research really needs to be done. And I dont think we have the answer to all of those questions.
But with respect to the subsidy policy, I mean subsidies are put in place for a whole host of reasons, right, protection for our farmers - lots of reasons, and so its hard to say, you know, the obvious answer is, oh my God, corn prices have been so low for so long - we need to do away with those subsidies.
And that seems, on the face of it, certainly when youre thinking about obesity, pretty reasonable. But I guess part of what Im trying to say is that we need to think about obesity as a piece of a much larger problem, and it may be that there are very good reasons for protecting our farmers or keeping these subsides in place, and it may not be, but all Im saying is, I dont think its so easy that we need to reduce these subsidies because of these rising rates of obesity, because there are lots of other factors why government may or may not think these subsidies are appropriate. But I will say the subsidies should be on a long list of things that government really should be taking a hard look at and saying, you know, these things made a lot of sense a few decades back when they were implemented, the world has changed, are they still appropriate, and I think we need to be systematically answering a whole host of those questions across governments -- state, local, and federal -- and thinking about whether these things do make sense today. I hope thats a little bit helpful.
Paul Ginsburg: Okay, yes.
Sarah Thomas: Hi, Im Sarah Thomas with AARPs Public Policy Institute, and this question is for Dr. Clancy. I was particularly interested in these elder learning networks, and my question is, have you seen results so far, and if its too soon, what kinds of indicators would you look for of success?
Carolyn Clancy: Thank you for the question, and I can promise you that Chris Williams will be happy to come chat with you anytime; shes very, very excited about this. So far what were seeing is communities actually taking the data, and were providing a lot of technical assistance for that, and literally mapping out very empirically based plans, and they simply have not had the capacity to do that. I think in another year well have some sense of early traction. But I would also say that one of our big challenges is knowing what are the key intervention points, how would we know if were making progress at any level from looking at a panel of patients, to a community, to even looking at NHANES. I mean what we can see, for example, from Erics data is, for obesity, were going the wrong way, but that doesnt mean that any of the questions that hes articulated, weve got any answers to.
Is it all because we dont have gym anymore? And I actually think thats very true for chronic illness, as well. So weve got a kind of artificial practical thing of looking at quality measures once a year or whatever. We have absolutely no basis for that except people can change plans once a year, so that feels like a good time to do it.
But we really dont know, and we dont know how to identify subgroups of people with chronic illnesses who would benefit from intensive intervention and what kind, and Im quite confident that Melanie Bella will be addressing some of this.
Sarah Thomas: Thanks.
Paul Ginsburg: Thank you. And weve got time for one last question; sir.
Josh Seidman: Josh Seidman from the Center for Information Therapy. There was a slide from each of your presentations that potentially might conflict with each other, but it may just be that clarification needs to be made.
In Dr. Finkelsteins presentation, you made the point that information campaigns are unlikely to have large impacts. Dr. Clancy had a slide that, the graphic, the 21st century health care slide, where one of the key points at the bottom of the circle was that actionable information available to clinicians and patients just in time, I presume that to mean that it was a critical factor in improving chronic care delivery. And certainly there is research from Ed Wagner and the chronic care models work to suggest certainly that timely, actionable, targeted, tailored information certainly is, and I just wanted to see if you were talking more about generic public education campaigns or if there is some disagreement there?
Paul Ginsburg: Yes, actually I think its clear that theyre not in conflict, but Ill let them explain.
Carolyn Clancy: Yes, I think the key word is actionable. I mean if making people feel guilty about obesity was going to work, I think wed start to see some dramatic declines. Clearly there is lots and lots of information about the problem. And I have to tell you the number one topic or line of research that we get calls for is on bariatric surgery, bingo. You know, a statistical brief goes up and instantly the phones and email start going.
I dont know that we know enough to say whats actionable, so that diagram is somewhat conceptual. Whats pretty clear is, I am seeing some leading edge health care systems that not only have electronic health records, but actually an internal strategy, begin to shift the content of an encounter from one that says, lets see Paul, right, so why are you here today, Paul, as youre flipping through a chart and remembering that Paul has diabetes and so forth, to actually a patient walks in with a chart and a map about where they are, where theyve had challenges and so forth.
I mean I think thats a very early and promising kind of development. Most systems actually dont have that kind of infrastructure, but thats sort of what Im imagining in the future.
Eric Finkelstein: I think you asked a great question. And let me give you sort of three anecdotes that sort of gives you my thinking on this. One is, you remember my little story in the beginning about these women in the program who were clearly told of their risk factors for heart disease conditions, and a year later they didnt even remember they were ever even told. I mean telling these women certainly didnt seem to have much of an impact.
If you look at what really worked to reduce smoking rates, as a second example, the general consensus is that the biggest single factor was cigarette taxes that got people to reduce smoking rates, and second to that was legislation about workplace and other smoking bans.
And so information had a role, but the evidence - in fact, Jon Gruber makes the point that he thinks nearly all of the reductions in smoking rates could be explained by taxes. Im not going to go that far. But certainly, I think these other factors played a big role. For obesity, I make the point that, or I believe, at least, that most people, by the time they get to be 30 or 35, probably already know that they have a weight problem and so telling them about their weight problem isnt going to make much of an impact. And, in fact, I have a published paper which I think would be great if you guys could take a look at which we actually asked obese people to rate their risk factors for obesity-related conditions, as well as their life expectancy, and what we found was that, compared to normal weight people, overweight and obese people clearly knew that their weight was putting them at an increased risk for a disease, and, in fact, they overestimated, based on the latest data, the mortality effect.
And so I take this evidence to suggest that people already know that obesity is bad for them, and they probably already know that their weight is a problem, but my feeling is, they also know, and probably have failed many times at trying to lose weight. And so just telling them, you need to lose weight, being obese is bad for you, isnt going to make a difference.
You need to change the environment, change the cost and benefits of these behaviors if you want to get sustained changes in behavior, and so thats really where my statement comes from.
Josh Seidman: Right, or the information needs to be more specific to the actions that can be taken to -
Eric Finkelstein: Its a necessary, but not sufficient condition maybe is a better way to say it.
Paul Ginsburg: In fact, another thought on that is that information - the impact is not going to be on individuals changing their behavior as much as setting the stage for the other public policy interventions that may be more effective, because, you know, clearly, it took a long time, and its still going on, to build the political support for the anti-tobacco rules that keep getting more and more stringent, like not allowing smoking in restaurants, and maybe we ought to think about more general public information about the down side of obesity as not so much influencing a lot of individuals, but influencing the policy environment for steps the government can take.
So weve run to the end of our time for this session, it worked out perfectly. Please thank the panelists. And at 10:15, or 10:17, well start the next session.
Paul Ginsburg: Okay. Id like to ask you to take your seats and well start the second panel. And now that we have a better understanding of the causes, the cost, and the consequences of rising rates of chronic conditions, our second panel is going to explore the role of different stakeholders -- employers, health plans, patients, Medicare, Medicaid, and physicians and hospitals in preventing chronic conditions and improving the care of people with chronic conditions.
Our first speaker is Melanie Bella, whos Senior Vice President in the Center for Health Care Strategies and a former Director of the Indiana Medicaid Program. Shes going to speak about public-sector perspectives on these issues.
Then well hear from Dr. Ron Goetzel, Director of the Emory University Institute for Health and Productivity Studies and Vice President of Consulting and Applied Research for Thomson Reuters Healthcare, whos going to look at the private sectors role, primarily health plans and employers.
Hell be followed by Dr. Michele Heisler, an Associate Professor of Medicine at the University of Michigan and a Research Scientist with the Veterans Administrations Health Services Research and Development Center of Excellence, whos going to talk about how the health care system could be redesigned to better serve patients with chronic conditions.
And lastly well hear from Dr. Kristin Carman, Co-Director of the Health Policy and Research Program at the American Institutes for Research, about the role of patients and some of the barriers that they face in accepting evidence- based health care and improving health care. Melanie.
Melanie Bella: Good morning. My name is Melanie Bella; I appreciate the chance to be here this morning. As was mentioned, Im with the Center for Health Care Strategies. For those of you not familiar with that organization, we are a non-profit health policy group in New Jersey. Like HSC, one of our major funders is the Robert Wood Johnson Foundation. And we work primarily in three areas, one is quality improvement, the second is reducing racial and ethnic disparities, and the third is improving care for complex and special populations. So it is in that area of complex and special populations that I do the majority of my work, all focused on helping state Medicaid programs become better purchasers of care for those beneficiaries that have the most complex and costly needs in the program. So I am thrilled to be here today to talk to you about the public-sector perspective. And while that will be rooted in Medicaid, I very much hope to convey that what we see in the Medicaid population is very relevant to Medicare, its very relevant to state employee plans, and to some of the higher cost portions of commercial populations, as well.
So as Dr. Clancy mentioned, the prevalence of chronic conditions is obviously significant in Medicaid. Its very significant with high need folks. The majority of people have more than one chronic condition, this is no surprise.
I think its worth noting that we have what we call the really high need beneficiaries, there are dual eligibles. Seven million people out of 55 million people on Medicaid are driving 42 percent of cost in Medicaid and close to 25 percent of cost in Medicare, so thats pretty significant if you think about it from the role of the public sector and the public purchaser.
And then we have really high costs. So youve all heard about the 5/50 - the 80/20 usually, were talking 80/20, 20 percent of people driving 80 percent of cost. In Medicaid its really the 5/50. So a little under 5 percent of people are driving 50 percent of the cost. Among the most expensive 1 percent of those beneficiaries, 83 percent have three or more chronic conditions and 60 percent have five or more chronic conditions.
So you might all look at this and think, this is a train wreck, what is in the world are we going to do about this. We look at this and say Medicaid is the land of opportunity. There is no better place to tackle chronic illness than in Medicaid.
By virtue of the purchasing leverage that Medicaid and Medicare combined have as purchasers of publicly financed care, and the complexity of the patient population, its a tremendous area to make a difference and to begin to learn whats going to impact both quality and cost outcomes.
So this is something, again, youre all familiar with, but it just - its the cost curve showing really the distribution of the cost and that a very, very small percentage of the population is driving a very large portion of the cost. And thats not to say that we want to focus entirely on the tail, the high right end, ideally were at a point where were keeping people in the middle from becoming on that high end. But right now Id say public purchasers have their hands full just managing some of the high cost folks.
So as Dr. Clancy also mentioned, weve been doing a lot of work looking at clustering of chronic conditions. So theres always been a lot of discussion about the fact that in Medicaid and Medicare, there are a lot of co-morbidities, but very little information available on exactly how do those chronic conditions cluster.
And so we partnered with some folks, Rick Kronick and colleagues at the University of California, San Diego, to do what we call a cluster analysis, which is produced in a report called the Faces of Medicaid II. Its available on our Web site; I encourage you to take a look. And the purpose was to help understand, to break down the complexity of chronic conditions within a Medicaid population, and to take a national data set made available to us by CMS and begin to look for patterns of chronic conditions. And the point again, Medicaid and Medicare have realized you cannot do the single disease focus siloed disease management programs, yet trying to figure out how to go from that all the way to a program thats going to be, you know, responsive and nimble to every single beneficiarys needs regardless of the set of chronic conditions was fairly overwhelming.
And so in an incremental step of breaking down the complexity, what this does, the Faces of Medicaid, and this is just one example, is goes in and looks for clusterings of chronic conditions.
So, for example, what you have here is, we did things in dyads and triads, if you will, pairs and sets of chronic conditions. And this one shows you the top five triads among the most expensive 5 percent of patients in Medicaid. So what we hope to use these tools to do is to help purchasers as theyre designing programs that they either want to implement in house or they want to contract with partners to go implement, help them understand, how do you break apart populations into subsets that can be better managed, and better managed by tailoring programs to better fit their needs.
And so, again, I would encourage you to take a look at this. Its just one way of doing it, but weve got to think about how do we break down the complexity and how do we begin to realize this is a very heterogeneous population and what are reasonable ways to think about developing cohorts to whom you may be able to map interventions that are better tailored to their needs.
So lets talk a little bit about public-sector challenges. The majority of folks in Medicare and Medicaid who are the highest cost and have the highest needs, with the exception maybe of some in Medicare that are being served through special needs plans, are still in a very fragmented, uncoordinated fee-for-service system. The very folks who need it the most are stuck, arguably in the worst place, and thats something that the public sector has a role in developing systems of care that are going to better manage the quality and cost of the folks who need it the most.
Reimbursement is generally insufficient to support what were asking people to do. This is a widely known fact in Medicaid in particular. It is no secret that Medicaid is not the best payer, and that the payment policies are difficult to do some of the prevent - definitely to do the prevention that was discussed in the earlier panel, and also to do some of the more complex care management. And this is particularly evident as states are rolling out medical homes, complex or advanced medical homes, and struggling both with state fiscal challenges, but quite honestly, also with CMS regulatory challenges about how to finance those medical homes and how to monitor them and measure their performance.
The Medicaid financing structure makes it difficult to invest in long term solutions, so as opposed to some of the federally funded programs, states cant run deficits, and when they need to get money to support some of these things, generally they have pressure to show a pay back within 12 months.
Well, thats obviously, as all of you in this room know, very difficult to accomplish, particularly when it requires investments in those very things that are going to make a difference. And so working with the federal partners and others to figure out creative ways to have some of that investment available up front, recognizing that it may take a longer time horizon to see some of those returns is really critical.
One of the biggest disappointments is to see a lot of the investments that have been made in Medicaid to date, but the plug gets pulled before weve really I think had a chance to see if the program is going to be successful, because its taking longer than people have to demonstrate results, particularly on the financial side, and thats a real shame, because we could really I think make a difference in if theres a long enough time horizon.
And then lastly, I could go on and on and on about this for hours, but since I only have ten minutes, Ill just say a personal obsession of mine, dual eligibles, and a huge frustration on both sides, Medicaid and Medicare, about the misalignment of the financial incentives. And that is the best example of where bad policy and bad financial systems impact folks who need care for the chronic illnesses that were talking about today.
So in the majority of Medicaid programs, dual eligibles are excluded from any chronic disease programs because the investment Medicaid makes generally is returned through reduction in hospitalization which accrues to Medicare.
And so those are some things that we just need to start dealing with when we think about how the public sector could contribute to helping alleviate some of the problems and burdens of chronic illness. So what are states doing? I love coming to D.C. because usually Medicaid is thought of as this mismanaged black hole and this awful drain on the system. And again, going back to Medicaid as the land of opportunity, states are great laboratories for innovation. There are incredible things going on in state Medicaid programs focused on the very population that youre talking about today, and getting the word out about that and figuring out how can we use those natural experiments that are going on today to help fuel the evidence based, to help fuel our information about these very difficult populations is critical.
So states -- theres a lot of focus right now on high-need, high-cost beneficiaries. This is very typical to whats going on in the commercial world. But states are identifying and stratifying these populations. Id say youve seen a lot of movement in both Medicaid and Medicare, recognizing that we need to focus on identifying and stratifying those patients that we think have - we have an ability to impact their utilization and their behavior as opposed to one-size-fits-all blanket care coordination approaches.
Theres much more activity in developing tailored care management interventions and new performance measures. The populations that were talking about today that have significant acute care needs, not to mention severe mental illness, substance abuse, long term care, physical and developmental disabilities, dont fit within the current measurement sets, or fit, but the current measurement sets arent enough, and so we need to do some work in that area. And then new financing is being tested in Medicaid and Ill talk a little bit about that.
Again, a little bit more about what states are doing. Fortunately, there is a huge focus on transitioning those folks who I mentioned earlier that are - I call them stuck in fee for service. Transitioning them into other systems of care, this doesnt necessarily mean traditional managed care as you know it, it means that there is some system and entity that is being held accountable for putting together programs that are intended to improve health outcomes and to improve cost.
Theres a tremendous focus on physical health and behavioral health integration. I would say that spans everything from co-location to coordination to integration and then some information sharing. But given the prevalence of mental illness, particularly severe mental illness in Medicaid, and also with the overlap in the duals, this is a tremendous area of focus. There also is a lot of energy behind full risk, well, behind different kinds of models in Medicaid. So for the aged and disabled beneficiaries, I think there is some caution into what sort of model, what sort of program to create, and so theres a lot of emergence of non-capitated models, administrative services organizations, care management entities coming in, again, having some accountability for improving clinical and financial outcomes, but not carrying all the financial risk, at least not on day one, because of the complexity of the population and the need to take it slowly and get it right.
Theres a lot of activity in integrating care for dual eligibles. Most noticeably and probably most talked about, has to do with arrangements with special needs plans. And, obviously, theres a lot of attention these days to requiring contracts with states over a set period of time for special needs plans.
While thats great, to try to think about how can we have a relationship for a beneficiary where that beneficiary is getting the benefits from the same entity, there are lots of states out there that dont or wont ever have managed care on Medicaid or Medicare side, and so we need options other than special needs plans, as well, to fuel integration across the country. And theres some discussion of gainsharing opportunities, so some plans in states are in conversations about gainsharing for improved care outcomes for the dual eligibles.
Im just going to give you a snapshot of two of the learning laboratories; one is New York and one is Colorado. Theyre both pretty different places. I love it when I go to New York, because when I was a Medicaid Director in Indiana, I think my whole budget was $5 billion, and thats just a rounding error in New York. I mean the magnitude of spending there is just tremendous. And, you know, were talking $45 billion spent in New York.
And if you look at this first bullet, 20 percent of those beneficiaries are driving 75 percent of that $45 billion. Again, think, land of opportunity, tremendous opportunity.
Ive listed there where their high cost beneficiaries, you know, six main categories, they will not be a surprise to you. One of the things that New York is doing is something called Chronic Illness Demonstration Projects, where New York will be providing funding to comprehensive provider-based entities to manage the care of the highest risk beneficiaries that are in fee for service, its a pretty exciting program. Colorado Medicaid, a similar story, 20 percent of folks are driving 77 percent of cost, 40 percent of those have multiple chronic conditions. Colorado has just implemented something called the Colorado Regional Integrated Care Collaborative, which is working with a health plan partner to take the top 20 percent of high-cost, high-risk folks in Colorado and manage them.
It includes wrapping around the high-volume practice sites with on the ground care managers, pretty exciting, as well.
I want to say also, both of these include a rigorous evaluation, where we have random assignment, so there will be a treatment and a control group to begin to tease out what is working in these places.
Promising new opportunities, and I know that my time is running short, so let me just say something that were referring to as the Faces of Medicaid 2.5. I mentioned before looking at clusterings of chronic conditions; the information in Faces of Medicaid was really helpful, but it doesnt take it necessarily to a level detailed enough for a clinician or a care manager or a caregiver to make actionable, because it relies on a diagnostic classification system that is essentially cardiovascular, for example. Well, cardiovascular can mean so many different things that we need to take it to the next level. So many of you may be familiar with the work of Cynthia Boyd and colleagues and Hopkins, and we have engaged Hopkins to do what were calling - to identify concordant and discordant treatment conditions. So they will be going in and looking at the clusterings of chronic conditions and separating out those conditions into those that have concordant treatment patterns and those that have discordant treatment patterns.
And this is, again, an attempt to help Medicaid figure out how do we want to prioritize these conditions and how can we better think about someone who has cancer and diabetes, how might we need something different than someone that has heart disease and diabetes, for example, in terms of treatment patterns.
This is something that could be very relevant to the Medicare population and to other high-risk populations, as well. Were also throwing in pharmacy and Medicare data. So thanks to CMS, we will be able to link Medicaid and Medicare data to begin to get a better picture on the duals. Ill talk a little bit about a national research agenda. Medicare has certainly contributed to the learning with all the demonstrations and the pilots. Medicaid has not been able to do similar - have similar support at a national level for demonstrations and pilots. And there are efforts underway to begin to have much more rigorous evaluations in Medicaid and to begin to develop what were calling a rapid learning network, so fitting in with what the IOM and others are doing in Medicare to bring that to Medicaid, as well.
The patient populations were talking about that have this chronic illness in Medicaid arent in the evidence base, theyre not in the clinical trial, so how do we develop a rapid learning network that lets us take observational analysis, mathematical modeling, you know, use the tremendous wealth of data at our fingertips within Medicaid and Medicare to begin to tell a story about whats working short of waiting three to five years for randomized controlled trials if we cant always get them.
And then Medicaid purchaser leverage, again, beyond the dream that Medicaid and Medicare will work together as public purchasers, there are places where Medicaid and the large commercial entities are coming together to do multi-payer initiatives for medical homes, for example. So agreeing upon a definition of standardization and a payment for medical homes so you can begin to aggregate. You can see how that could be built into working on areas of certain chronic disease priorities, as well.
And the last is, a lot of the reason why were able to go do all this - do all the things on the high cost chronically ill today is because probably every other governor, if not two-thirds of the governors, have all announced coverage expansions. And so the linkage between getting control over the high-cost folks in Medicaid and freeing up dollars to use for coverage expansions, it provides some great momentum.
And so right now we feel like theres a lot of opportunity to, again, use the complexity of the patient populations in both Medicaid and Medicare as a reason to be able to go do some of the other policy initiatives that are of interest across the country.
Now, I think the jury is still out on whether any of this is working. But certainly doing it in a more structured way and trying to provide some evidence is a first step. So, again, I realize this was pretty grounded in Medicaid, but I do think its relevant and that theres a tremendous opportunity for the public sector to contribute to the solution and not just be part of the challenge. So thank you very much.
Ron Goetzel: Hi, good morning. Im Ron Goetzel; I want to thank Dr. Ginsburg and the Center for Studying Health System Change for inviting me to talk this morning. Im going to be focusing primarily on the employer role. During the Q and A, we may have an opportunity to talk about health plans and what their contribution is in terms of prevention and health promotion and how theyre working with employers.
But Ive been working with employers for about 25 years now, and many of the innovations that have come about in health care have started in the employer sector. If you think about quality initiatives, HEDIS, prevention of mistakes, managed care initiatives, health and productivity activities, all of those really found their birth in employer experiments, which in many ways have grown and expanded and become part of the landscape and the culture of health care delivery in this country.
There is much more of a movement today focused on health promotion and disease prevention as part of a broad health and productivity management umbrella, and that does include health and safety issues, it does include disease management, chronic care management and so forth, and it is an attempt to be much more coordinated in the care of workers. And if you think about it, you know, everyone in this room, I think, is employed, so about 95 percent of the working age population who wants to work is actually now employed, and that represents somewhere around 160 million Americans in the United States today.
And theres a lot of innovation going on in the employer sector, and I think we can learn from their experience, but also there are a number of policy implications that we can take away from that experience and apply more broadly.
So Ill start with, you know, the picture of the woman with the huge headache, and shes worried about our spending on health care, this is, you know, a figure youre all familiar with, two and a quarter trillion dollars, private sector spending a little over half of the amount of that, health care expenditures increasing, you know, the latest figure is somewhere around 7 percent, and health care as a part of GDP being roughly 16 percent, but its going to increase dramatically in the next few years. This is what it looks like from an employer perspective. These are the estimated annual premiums that employers are paying, roughly around $8,000 a year for 2007. And a question, of course, is, why is health care so expensive, why is it rising so dramatically.
This is a picture of my boss at Emory, Ken Thorpe. A requirement of my contract is that for every presentation I make, Ive got to have a picture of my boss somewhere in that presentation, so hes there.
Hes done a lot of research in this area, and bottom line, hes shown that about 37 percent of the rise in health care expenditures is due to increased spending for treated diseases, and innovations, and advancing technologies.
And we have a list here, Im not going to go through all of, in terms of all the great things that have happened in the last 15 - 20 years in terms of improved technology and care for the treatment of chronic disease and otherwise, as well as establishing new thresholds for treatments. You know, the mention earlier about children receiving statins, well, you know, thats yet an expansion of the kinds of care and the amount of care that were providing. And, of course, down at the bottom is waste. Waste continues to be a problem, because currently, by and large, the way health care system is organized in the United States is that the more you do, the more you get paid, and until recently, the more mistakes you made, the more you got paid for that, as well.
So as Alain Enthoven says, you know, a key to the solution is to make the system more efficient and more effective, absolutely. But thats only going to take care of 37 percent of the problem; 63 percent is what Dr. Finkelstein talked about, which is a rise in prevalence of disease, and huge amount of payments that were making for the care of chronic disease, and 27 percent of the total increase in the rise in health care costs being due specifically to obesity.
And again, I wont repeat the statistics that were presented earlier, but we can see a tremendous growth in obesity rates, partially due to individual factors, but largely due to environmental factors, and if we have time, I can talk about what the employer community is doing to change the environment and ecology of the work place to address that. So most employers are saying what do I do, and theres a long list of things that theyre trying, from managing disease, disability, absence, health demand, stress incentives and so forth, a long list of different interventions. A question, of course, is, an empirical one, do any of these things actually work, you know, do they make a difference. And theres very little real world research that has examined these types of interventions programs in employer settings to test whether they are effective in improving health and saving money.
The what to do list, this is the latest what to do list that was created by the National Business Group on Health, it has number two on the list, and thats been promoted from number five before. Number two is they actively promote health improvement programs and resources.
And so were seeing a sea change in terms of the number of employers that are beginning to think about and implement these kinds of programs in the workplace. The main problem out there is that they dont know how to do it and they dont know how to do it well, and theres a lot of bad doing of these kinds of programs.
In fact, a study that was just released that looked at employer efforts and health promotion disease prevention showed that even though roughly 90 percent of employers report that they have health promotion programs in place, when you look at the categories and the ways in which these programs ought to be structured in terms of their comprehensiveness, the actual number is closer to 7 percent. And so theres a lot of stuff, a lot of activity going on out there, but most of it is actually not very effective.
So you can scratch your head, and if youre in the elevator with the CEO and CFO and they ask what youre doing, you can say, well, doesnt it seem logical that if you improve the health and wellbeing of your employees, their quality of life improves, health utilization is reduced, disability is controlled, and productivity is enhanced. And for most people, that does seem very, very logical and intuitive.
There is strong evidence that these things do work, and its a progression, a logic flow of evidence. Very little doubt and hesitation with the first bullet that says, a large proportion of diseases and disorders is preventable, modifiable health risk factors are precursors to a large number of diseases and disorders and to premature death.
We literally have tens of thousands of epidemiological studies published week in and week out in JAMA, New England Journal of Medicine, that confirmed that relationship. Many modifiable health risk factors are associated with increased health care costs within a relatively short time window; again, theres a growing body of evidence that thats true.
Modifiable health risk factors can be improved through workplace-sponsored health promotion, disease prevention programs. That evidence is also growing. In fact, the latest set of research and compilation of research was released last year by the CDC Community Guide Task Force, and they essentially came to the conclusion that there is strong and sufficient evidence that many of these workplace health promotion programs do have a positive impact on behavioral, biometric and financial outcomes.
Next, improvements in the health risk profile populations can lead to reductions in cost. Some seminal work by D. Edington, University of Michigan, other work, some work weve done, has shown that relationship, although its not as strong as the earlier bullet. And then the evidence that these programs, if theyre evidence-based and properly implemented, can actually produce ROI, return on investment, and there is a growing body of evidence there. Ill just share some of the evidence in a couple of minutes on that. Theres no question that diseases are caused, at least partially, by lifestyle. And we have here a list of the lifestyle factors and all the consequences of diseases that follow.
For the employer, this also costs them money. Now, it costs them money on many dimensions. It costs them money in terms of direct medical costs, absence and work loss, presenteeism, which is on-the-job productivity loss. This is when people are physically present, but mentally or otherwise, theyre not there performing at optimal levels simply because of certain risk factors or health conditions that are impeding optimal performance, and then the risk factors that precede all of these.
Weve done several top ten research studies where weve looked on a per capita basis at what are the most expensive health conditions that affect employers. This is one that connects medical absence and disability. And as you can see, on a per capita basis, its angina, hypertension, diabetes, low-back disorders, AMI, COPD, obviously conditions that have huge lifestyle components associated with them. And its not just medical, but its also absence and disability. And then if you expand the view and bring in the notion of presenteeism, again, people going to work, having certain health conditions, but their productivity at work is impeded simply because these conditions are not well managed, you can see that the costs rise quite dramatically.
And, in fact, our estimates are that for every dollar, about 60 percent of that dollar is actually linked back to presenteeism losses.
And in terms of the precursors, the risk factors that predict these increased costs, this is a study we did with 46,000 employees called the Hero Study, which looked at ten modifiable risk factors, looked at independently, and it was psychosocial factors, depression and stress, that were most expensive compared to the other conditions. But if you look at them in aggregate, about 25 percent of these employers costs were linked to these ten modifiable health risk factors.
Some examples of case studies, where the organization has looked at the health and economic consequences, Im going to be focusing primarily on the economic consequences, not so much on the health consequences, although in each of these studies weve published papers that have looked at health impacts, as well as financial impacts. Citibank, a study done back in the 90s, 48,000 employees eligible for the program. Program savings, when you compare participants and non-participants, roughly $1.9 million. Im sorry, that was program expense, $1.9 million, program benefits $8.9 million, so a net savings of $7 million from that program, and a return on investment of $4.70 for every dollar invested.
Johnson and Johnson, the granddaddy of health promotion programs, started back in the 1970s, and continually upgrading and innovating in terms of the design of their programs; in fact, most recently providing a very substantial financial incentive to participate in the program, $500 incentive to participate, which actually doesnt cost Johnson and Johnson a penny because the premiums are based upon that $500 incentive already built into the calculation. So its really the non-participants who are being taxed $500 for not participating.
And that produced for them 94 percent participation rates. The 90-plus percent participation rates are becoming much more common as these kinds of benefit plan designs are structured so that there is a very substantial incentive to participate in the programs. In Johnson and Johnsons case, about a $225 per employee per year savings, which actually grew incrementally over time. Procter and Gamble, Cincinnati, Ohio, 8,000 employees there in headquarters, 4,000 in the intervention, 4,000 in the comparison group, and after three years, a 29 percent difference in total medical expenditures between participants and non-participants.
Most recently we published a study with HighMark in Pennsylvania, where we looked at a very comprehensive program targeted at 12,000 HighMark employees, on average saved $176 and a half dollars per employee per year, and this is what the trend line looked like in terms of participants and non-participants, which were very, very closely matched to one another using propensity score methods. Over the four-year intervention period, the return on investment on a cumulative basis was roughly $1.65 saved for every dollar invested.
So what are some policy implications? And whats interesting here is that these experiments were not government mandated programs, these are not taxable programs, these are not things - regulations that the government imposed, but essentially employers taking the initiative to introduce these programs and to fine tune and experiment and develop these programs based upon their experience and the experience of others. However, there are some policy implications out there that we can consider. For example, number one on the list is to pass Tom Harkins Health Work Force Act. And what this act would do is provide companies financial incentives, tax credits of up to $400 per employee per year, so that when they institute bona fide health promotion programs, they could get back that kind of credit for that investment.
That credit would be reduced in year two, and then actually disappear, moving forward. But it would be a significant incentive for employers to invest in these kinds of programs because they can realize a very quick return on their investment in terms of a tax credit.
There are other bills out there that would provide financial incentives and tax credits, not just at the employer level, but also at the employee level, so that they could, for example, get a credit or a deduction for a health club membership or Weight Watchers programs or other community-based programs.
The government can also sponsor venues for public recognition of exemplary programs and business leaders supporting these programs. The best example of that I think is the annual C. Everett Coop Award. This year 21 companies applied for the award, and five companies will be given the award in September at a conference, where Dr. Coop will, at age 93, will hand out the award to five organizations who have been able to demonstrate health improvements and cost savings.
Identify and disseminate best practices; theres a lot of ignorance out there in terms of what works and what does not, and a lot of things that dont work are being put in place in these companies. And so there can be a lot of knowledge that can be distributed, disseminated, communicated to organizations that want to put these programs in place.
And coupled with that is establishing public-private technical assistance and consulting services to support employer efforts. We were involved with the New York City Department of Health, a three-year study funded by the CDC, that provided that kind of technical assistance and support to ten employers in New York City who wanted to implement internal health promotion disease prevention programs.
Increased funding for real world research demonstrations; large-scale studies, the studies weve done, typically involve tens of thousands of people, and thats the way you really want to conduct these studies, not with 200 or 300 people, but do it on a very large scale to see if you can create even small reductions in the risk profile across many thousands of people actually translate to a large public health impact and substantial cost savings.
Other policy options, introduce federal legislation promoting workers health. Examples, which were mentioned earlier, smoke-free workplace policies. The next one, initiate pilot studies at local, state, federal agencies that test innovative models of health promotion among public employers.
Its, again, very interesting that most of the innovation has come from the private sector. But wouldnt it be nice if state and federal and local health departments and public agencies instituted these programs in world class fashion and then experimented and determined whether these programs worked among their own employees.
Make available tools and resources that employers can use to run programs, evaluation instruments, financial modeling programs like the one Dr. Finkelstein has produced that looks at the return on investment from obesity prevention programs, establish ongoing measurement and performance tracking systems specific to workplace health promotion, and reporting relevant metrics related to employer efforts, for example, healthiest places to work. If the government were able to support that, then people would be able to go to those companies where they know theyre going to be supported in terms of their health improvement efforts. And then finally, a sure, clear focus on the workplace as part of strategic planning for health policies and programs.
So to summarize, I think theres a growing body of literature out there, in fact, there are over 50 studies done in corporate settings, real-world applications, that suggest that if you do things that are evidence-based, well designed, well implemented, well evaluated, that these kinds of programs can improve the health of workers, lower their risk for disease, save businesses money by reducing health-related loss, and limiting absence and disability, heighten work morale and work relations, improve worker productivity, and then overall improve the financial performance of organizations that institute these programs.
And in the Q and A, you know, we can talk a little bit about the kinds of environmental and policy interventions that some employers have introduced in order to make this happen. Thank you.
Michele Heisler: Good morning and thank you. So now we turn to the health system. And a number of speakers before have talked a little bit about the health system, but in the next ten minutes, I want to talk a little bit about - just quickly summarize some of the deficiencies in the health system, and then talk a little bit about some of the main components that current research shows are most important.
Im trying to lay out some key principles and then I hope that well have a chance in the question and answer to talk about some more specific examples, as well.
As a number of speakers have talked about earlier, the current state of chronic disease management and prevention in health systems is still very poor. The major RAND study many of you are familiar with found that Americans with chronic health problems receive recommended care just over 50 percent of the time, and those statistics are similar for receipt of necessary preventive care.
We know that less than 50 percent of Americans have satisfactory levels of disease control as measured by outcomes such as A1C and diabetes, blood pressure control, control of cardiovascular risk factors. Numerous national surveys show that the majority of Americans dont feel that the chronically ill get good care in the U.S. And physicians and other health care providers are very frustrated with chronic illness care.
Sometimes people think, well, you know, are there differences between the private sector and academic medical centers, maybe at our premier academic medical center things are better. Review of care in academic medical centers in 2005 found that thats not true.
Even in academic medical centers, and even when you compare general medicine practices with specialized diabetes and endocrinology clinics, key measures of control for diabetes, such as having good blood sugar control as measured by an A1C of less than 7 percent, we found that in 34 percent in general medicine had achieved that target level, and only 34 percent in specialized diabetes clinics, blood pressure, which is actually more important in type 2 diabetes than blood sugar control, only 30 percent were at the target blood pressure level, a little bit better in diabetes.
So its not necessarily academic medical centers versus non-academic medical centers, and its not true that specialists are necessarily doing better than general medicine. Its important to talk a little bit about some of the factors that health care systems arguably should be the ones doing such an intensification of medications. Many of you are familiar with the term clinical inertia, and there are numerous studies that show that health care providers are not getting patients on the right doses and numbers of medications.
I wanted just to show one example of this. This is data from Kaiser Permanente, which is one of the best integrated managed care systems, has very innovative programs, well talk a little bit about some of the components.
And even at Kaiser Permanente, when you looked at patients with diabetes, patients that had been just on diet and exercise to control their diabetes, on average, they stayed nine months over an A1C of 8 percent; again, thats significantly higher than the target level of 7 percent for sugar control.
Their average A1C at intervention was 8.6 percent, so they were put on one medication. That didnt work. Then, on average, patients stayed 20 months on one medication, not without a quick blood sugar control. When they were put on Metformin as the only medication, they stayed on that for 14 months, letting their A1Cs hover at about 9 percent. And then when patients were put on two medications, Metformin and Sulfonylurea, they stayed 26 months on those medications without insulin being started. By the time the provider got around to starting insulin or discussing insulin, their average A1C was 10 percent. And this is at Kaiser Permanente.
So, again, we health care systems, one thing we should be doing is recommending and prescribing the right medications; and again, numerous studies show that that is not happening.
Another important issue, and again, Dr. Clancy and others have really focused on this; we know that even when providers are prescribing the right medications, numerous studies show that about 50 percent of patients with chronic diseases take their prescribed medications, and we know those numbers are even worse for diet and exercise programs.
The costs of this are huge. Just counting unnecessary emergency room admissions, preventable hospitalizations, the costs of poor medication adherence alone is greater than $100 billion a year. As Dr. Coop, who has been mentioned before, said, memorably, drugs dont work in patients who dont take them. Heres a nice pyramid, and this has been touched on before. Its useful to think about where does the bulk of chronic illness care happen in the U.S. And again, the huge part of the pyramid is the care that the patient, the self-management that patients themselves have to do between office visits.
And I think its really important in all these discussions that we remember this, that chronic disease outcomes depend critically, once patients are on the right medications, once they get appropriate advice and support for self-management, the bulk is what they have to do between office visits.
And then the next most important level is the primary care level. Just speaking of diabetes, 95 percent of patients with type 2 diabetes get their care from primary care physicians. You know, theres not even enough endocrinologists to refer. So I mean, again, most patients are relying on primary care for their disease management, with a little bit less in secondary and tertiary care.
Lets think a little bit about the current encounter as we think about this. And again, I think most of - this is what most of us are familiar with when we go to our doctor. So you think of Mrs. Davis, she has diabetes, hyperlipidemia, hypertension, and COPD; every day she has to take all her medications, she has to follow a diabetes and low salt diet, she has to try to exercise and maintain physical activity, she has to monitor and respond to her symptoms, she has to carry on with her life as best she can.
Then you think of her doctor. So her doctor has about 1,500 patients. When Mrs. Davis comes in, as we know from research, her doctor often doesnt have necessary clinical data, she almost certainly doesnt have data at her fingertips on hospitalizations.
As we know, I think more than 50 percent of primary care providers never get discharge information on patients that have been hospitalized, so she has to spend time finding out about hospitalizations.
We also know that if she were to follow recommended guidelines, every day she would spend about seven hours providing recommended preventive care, and 11 hours providing recommended chronic care, all this within the 15 minutes shes allocated for each patient.
Mrs. Davis and her doctor are working as hard as they can. And I think as all of us are familiar with, especially since the Institute of Medicine report really emphasized this, that everyone is working hard, but current care systems cannot do the job, we have to change systems. And so I want to talk a little bit about whats known about what are the key components. And in talking about this, some of this is the minimum, and then I want to talk a little bit about how once you have these basic frameworks, some of the innovative work being done to go even farther.
So patients need a continuous and coordinated healing relationship, and they need a care team thats organized to meet their needs for effective treatment, and thats clinical, behavioral, supportive treatment, they need information and support for their self-management, they need systematic follow-up and assessment tailored to their clinical severity, and as Melanie Bella was saying, also in terms of their clustered particular conditions, knowing which ones require more priority, and they need coordination of care across settings and professionals, and very importantly, they need linkages with effective community resources.
As some of the other speakers were saying, especially when we talk about preventive care, were going to need the health care system to be interacting effectively with a range of community sources. You know, we need services, I need to refer somebody to a YMCA program that will provide coaching and sustained support.
Studies have found that high-quality chronic care requires a systematic and organized approach. And I think whats really interesting as you start looking at the research coming in, one of the most important features, once, you know, you need clinical information systems, you need decision support, but in particular is effective coordination and collaboration among all available personnel within a practice, and coordination with external resources, coordination with specialists, whether thats through electronic referral, as Dr. Bodenheimer talked about in his recent paper, coordination with diabetes educators, behavioral coaches, maybe its community health workers, peer supporters, its a team-based approach.
And this may be a very tiny team within the practice. I mean 40 percent of primary care providers are in one- or two-person practices. So it may be a little, as Dr. Bodenheimer called it, a teamlet, where its the physician and the medical assistant being trained to do some of these team roles. Again, as I noted before, its the design of the care system, not the specialty of the physician, and again, this very important role of teams for improving chronic illness care. Quickly, what are the four key areas; and when you look at health care system interventions, proposals, I think there are four key components, these are the four key components that Wagner outlined in the chronic care model, and these are the components as you look at different interventions that you want to evaluate, do they include work on all these levels.
So one is delivery system design, whos on the health care team, how are we interacting with patients, what kind of decision support is there, what kind of support is there ensuring that theres the best care and how we make it happen every time, you know, something flashing out that says this woman hasnt had a mammogram in five years, or look at this patients blood pressure, you know, red flashing, even just basic clinical information systems.
But then once you have that in place, you can build on them, and Ill talk a little bit about that. And we need self-management support, how we help patients live with their conditions and make behavioral changes to improve health. Quickly, I think most of you are familiar with this research, there have been a number of collaborative reviews and - reviews that have shown that studies that include all of these elements lead to better patient outcome. So again, if you have all of the elements, youre working on decision support, delivery system design, information systems, and self-management support, patient outcomes are better.
Also, very importantly, 19 of 20 studies which included a self-management component improved care. Another study, again, looked at 134 managed Medicare organizations. This was focusing on diabetes, quality of care, and they, again, looked at these care elements that have been based on the chronic care model, reminders, guidelines, registries, self-management.
When they compared the top and the bottom quartiles in quality, the top quartile was much more likely to employ elements of the chronic care model. In particular, computerized reminders, you know, reminding the provider, you have to do this; practitioner involvement on quality improvement teams, guidelines supported by academic detailing, and formal self-management programs, and a registry. A 2005 AHRQ-sponsored systematic review looked at quality improvement interventions in blood pressure and concluded that organizational interventions that assigned non-physician staff to address chronic disease management had the largest effect on outcomes. The smallest effect was among interventions that just focused on individual providers. Weve just got to educate the providers more, weve got to - those had, by far, the lowest effect.
Patient activation interventions were much more successful than interventions that just focused on changing provider behavior. Critically, though, just adding team members is not enough. A key ingredient for most successful interventions was allowing a nurse or a pharmacist or other case manager actually act on values.
So, for example, if you identify someone with high blood pressure, the pharmacist or the nurse is empowered to make the recommended medication changes, not waiting to refer it back to the physician.
And again, when you start thinking about these different elements, you can see how you can really build on this. So, for example, we in the VA and Kaiser colleagues are starting an intervention, again, we have very good clinical information systems, so we have information on all our patients that have high blood pressure. So if you have diabetes and high blood pressure, we have that information. Were training clinical pharmacists in motivational interviewing, and again, this isnt the focus of the talk, but I would argue that its not just all these other elements, but how were supporting self-management. So we know that advice, as Dr. Clancy said, advice alone does not work, supporting motivation and self-confidence does. So were training clinical pharmacists in motivational interviewing, and then they are proactively reaching out to patients with diabetes, with high blood pressure.
Because of the superb clinical information systems, the pharmacists will know which of these patients have had difficulty filling their medications, because they have information on medication refill gaps. They also will have information on patients whose providers failed to intensify their medication.
So if a patient doesnt have any refill gaps, and we see that their provider did not intensify their medications, the clinical pharmacist can proactively reach out to these patients, can assess adherence and help them address their barriers to adherence, or if theyre not having problems taking their medications, the pharmacist will be able to intensify their medications. A couple of important things that we can do in visits, again, increase the role of non-physician staff. We can do much more with patients waiting times, we can do computerized assessments while theyre waiting. Even in efficient practices, theres a lot of time patients sit in the waiting room, and you can do computerized assessments. Do a diet assessment.
You know, theres some studies that show, you know, do a good diet assessment or a physical activity assessment, and then that information is available to be acted on.
Also, a lot being done with innovative clinic-based programs, like group visits, Kate Lorig type self-management training and support. And again, the key role between medical visits, so case management, interactive voice response systems, where patients - high-risk patients -- can provide information through a telephone system, forging links with community resources, much more use of community health promoters and peer support, and creative uses of telephone and computer technologies.
Research shows that if you link these mechanisms with usual clinical care, theyll be much more effective. And theres a lot being done on interventions to support adherence. Again, Ill let you read that, because I want to make sure I keep to my time limit. So again, as we think about health care system interventions, we need to think a lot about how are we improving the relations between the patient and primary providers, pharmacy, care managers, medical assistants, the whole team.
But theres also more that we could be doing in terms of buttressing peer support, how do we better mobilize patients to provide support to each other, how do we better mobilize families and informal caregivers.
So what the outcomes - if we can start thinking about these key components, ideally what were looking for is well-organized, efficient practices, satisfied patients on the right medication, with excellent self-management and healthy behaviors, and satisfied providers, able to provide outstanding patient care without feeling overwhelmed. Thank you.
Kristin Carman: This has actually been a very interesting conference for me to be at, and whats been interesting in these different talks that youve heard so far have really ranged from very broad, big picture views for thinking about chronic disease, to some more specific conversations about what employers are doing, what health plans can be doing, and some specific cases, and obviously Erics discussion of obesity, in particular.
And weve talked a lot about information and communication, and what Im going to talk to you today about is a communication project. I think where communication really is crucial and important is, communication has an impact on peoples motivation, has an impact on how people view themselves and their values and their beliefs.
As a sociologist by training, I think those can have a huge impact on the things we do and how we see the world. And it was interesting, Eric talking about obesity and the impact of taxes and tax behavior on smoking. I think thats important, although theres a sociologist who wrote a book about the changing norms and values around smoking in the early 1980s which talked about turning smoking into a form of deviance. In many ways, our ability to legislate on many of these issues is often times affected by how our values and our norms alter about these kinds of things, which isnt to say either perspective is right or wrong, its simply to say it is often the combination of these things that matters.
And, of course, communication and how we communicate with people is an important component. It is just one piece of a very large picture of the need for incentives, and structure, and processes. So this is a piece of this larger mosaic were talking about today. So I wanted to use that as sort of a backdrop.
This project was actually a project to develop a communication tool kit for employers, interestingly enough. I put the slide on here just as always in projects like this to mention the many people involved. The project was funded by the California HealthCare Foundation. It actually included an advisory group with representatives from business, employers, many kinds of folks doing work in this area, and also actually AHRQ, as well.
Let me talk a little bit about what led to the development of this tool kit. And Im going to talk about our findings, and Im going to talk about what led to it, because it gets back to these questions of, what are the issues out there that employers are very concerned about, and Dr. Goetzel just talked a little bit about this. This project was initiated at the behest of the National Business Group on Evidence-Based Medicine, which is sponsored by the National Business Group on Health. It has a lot of employer members, it has federal agency members, including AHRQ, as a matter of fact.
This project was initiated because this group anticipated tremendous resistance to evidence-based design changes. So were just talking about what are these different ways we can alter incentives and different things in the workplace, different kinds of workplace programs.
They were very concerned that while they were attempting to put into place Evidence-based approaches to benefits design, things that would work and were shown to work, and also to try to alter the behavior of their employees based on changing their benefits designs to see higher performing providers and to do things like, were going to have you pay less or pay nothing for certain kinds of care and what not, that there was going to be employer resistance to these ideas and these concepts.
And they wanted to maximize the receptiveness and understanding of evidence- based approaches, and were themselves quite concerned about what the reaction was going to be to the kinds of things that they were trying to do. Now, interestingly enough, though, the project was broadened to really focus on a range of issues concerning the potential misconceptions and concerns or reactions to evidence- based health care.
So our project was really expanded to go much beyond thinking about just evidence- based design, but sort of how do consumers and patients react to some of these concepts. And youre saying, well, evidence-based, that sounds sort of very narrow.
Well, in fact, we used a very broad definition in our formative research and to develop the communication tools. So if you think about it, evidence-based refers to using results from medical research that produces evidence about how well treatments work, treatments sort of broadly.
So for employers, communicating with employees about evidence - communicating about evidence to guide treatment choices, to assess the quality of cost-effective care, to promote disease and wellness programs, chronic disease management programs, these were all arenas in which employers were likely to have to be communicating with employees about evidence behind why were doing these things, why you should do these things, why these things are important to you. And so we adopted a broader view, it was because they are communicating on all these many different issues and making substantial changes in their benefit structures based on this evidence and communicating with folks about these.
And from our perspective, we were trying to use an evidence-based approach to communication; how can we best communicate with people on these issues, what are potential barriers and facilitators to the doing of this.
And I guess the thing, and I sort of said it before, but communication is important, because what we learned is, consumers may have some key stumbling blocks to understanding and acting on key concepts underlying evidence-based health care. And this means that some existing information and supports may not be as effective as they could be.
It doesnt mean theyre ineffective, it simply means that some of these conceptual gaps and knowledge and misconceptions can create some stumbling blocks to people being able to hold onto this information, act on it, because again, communication and information, while not a sufficient condition for everything, can have an impact on peoples attention, motivation, and frankly, their self-efficacy, which is a huge component of self- management. And so Im not going to spend too much time on this particular slide other than to note that we did - for the creation of the tool kit, weve spent a lot of time and a lot of research in order to do this, focus groups and individual interviews.
But we were trying to understand what are employers and unions doing to communicate on this topic, what are the things that they really need help and support with communicating about, what do employers need help communicating about, what do employees need help with, and what are consumers attitudes and beliefs on this topic when we think about it more broadly.
And so when we were doing studies like this, we were asking consumers and trying to get at what kind of communications have you received, on what kinds of topics. We used very specific examples of evidence on quality and different kinds of information to get the reactions to the employer and different benefit designs, so if an employer wants to do this, how would you react to that.
We tried to make it very concrete and very explicit. Id be happy to go into the details. I dont have that much time today, Im going to have to spend more time on the findings, but Id be happy to talk to folks about that. So what did we learn about the challenge we face communicating with consumers?
And I think - I was thinking about this for a chronic disease group, why is this so important? Because I think it affects all the different ways in which were communicating with people on a lot of different topics. And as we go into these, I think I can make that a little bit more clear.
But we really can synthesize our findings into three themes. Consumers can sometimes have very different beliefs and conflicting values than the ones that were espousing on some of these topics. Consumers dont necessarily trust some important communication channels. In any communication interaction, theres a sender, theres a receiver, and individuals are not just reacting to a message, but theyre reacting to a sender, and sometimes misconceptions and biases and gaps and knowledge can have a real impact on how people take in that information, whether it motivates them to action or assists them with action. In addition, consumers have limited experience with becoming more actively involved and find it hard to engage. And while all this doesnt seem surprising in some ways, when you pull it all together, it really does sort of identify some range of things we have to try to tackle.
So let me start with the first one. In our focus groups specifically, consumers had extremely limited knowledge and misconceptions about the concepts embedded in evidenced-based care. Again, were thinking about this broadly, using evidence to suggest you to do all kinds of things.
They dont understand guidelines, they dont always understand where best practices come from, who makes these things, who creates these things, well talk a little bit more about that.
And even in our focus groups, when we explain the concepts of guidelines that outline the best methods of treating certain diseases or conditions, even when we provided detailed explanations, their understanding of the general principles behind this were tenuous, at best.
So theyre unfamiliar, most of them obviously havent had interaction or communication with the physicians, and they have some pretty negative beliefs about guidelines. So when you say guidelines suggest you do this, guidelines suggest you do that, this is what many of them have in their head. These are about restrictions on my choice. Theyre designed to protect everyone but the patient. They represent an inflexible, one-size-fits-all approach. Im an individual. What do you mean standardized care around certain kinds of issue?
They also think sometimes it can be barriers to medical innovation. They also sometimes think they can be biased. Well, whos writing those? Its those ten people who made those up.
And so while evidence-based health care values using medical evidence and quality standards to make decisions, reducing under use misuse and overuse, and encouraging people to be actively engaged, sometimes when were talking about these issues, our consumers are not always on the same page when were using these terms.
Consumers also believe that more care is better care. So when people believe that more care is better care, its hard to accept that evidence says its otherwise. Its not impossible, by the way, because one of the things Im going to talk about is, there are ways of attenuating these. And I want to say this because I see Dr. Clancy in the audience, because weve had conversations about this. The point of figuring this stuff out is not to say that consumers cant get this, theyre not capable of understanding this, of course, they are. The point is, we have to understand where they are, we have to understand some of their challenges in order to communicate more effectively with them.
So we should - when we know that, to them, more care is better care, its hard to accept evidence otherwise. It doesnt mean you cant communicate with them, but you better understand, thats where theyre starting from.
And, frankly, for example, the idea that getting less care could actually mean getting the right care or better care was completely counter intuitive to some people. I mean they were just flummoxed in the focus groups and sometimes in the individual interviews.
And when people believe that good quality costs more, its hard to accept evidence that good quality can actually cost less. And this is one of the quotes that - and here we have - because if youre going to have a doctor thats better, hell charge you more. There was one person spontaneously in the group when we were talking about a benefit that you could pay less to see doctors, she just said, that cant be, you dont get something for nothing, thats just not the way that life works. So some of it is just peoples commonsense understanding. And when people believe theyre unique, its hard to accept uniform standards of care.
In addition to sort of having conflicting beliefs and sometimes values, they dont necessarily trust important communication channels. And I know this isnt necessarily news, but certainly people feel very bombarded with competing demands for their time and attention and they feel really inundated.
And so with that limited amount of time, whats in it for me, how is this going to help what I already have to do? And sometimes you can tell people, weve heard that you know, people heard something, a year later they dont remember being told it, part of it is because theyre just not attending to it, got lots of other stuff to attend to, and it hasnt risen to the level of where this is really important for me to know about.
One reason obviously a lot of this stuff seems relevant is the notion that quality varies, doesnt really impact people. The notion that theyre not getting things they should be getting doesnt really make sense to them, or that theyre getting more things than they should get than other things, and they often times think what theyre getting and what theyre doing is absolutely fine. But this notion of being inundated with information is exacerbated by not necessarily being so clear about who to trust. Again, not necessarily a surprise to us, but its important.
So key channels to communicate with folks are health plans and employers, and neither of whom are particularly trusted by folks. Well talk a little bit more about some of the concerns with employer communication.
Please also note the difference in sites. People are very trusting when you say medical school sites and hospital web sites, and for them, that was like Harvard and things like that. When youre talking about other sites, they have much less of a sense of, well, whats this information, and wheres it coming from, and when its telling me Im supposed to be doing all these things, Im not so sure that it particularly helps me.
And we also know, obviously, when people get on a Google pathway, they dont necessarily know where they are or how they got there, which can have a huge impact. And in these - obviously this project was requested from a group of employers who were particularly interested since theyre sort of at the nexus, and in some ways, ground zero of a lot of these issues -- peoples reactions to their trying to convey and providing information and supports and tools to people in order to do this stuff.
So they tend to be especially suspicious because theyre afraid, obviously, that employers care more about saving money than helping employees and are overstepping their bounds. Theyre very concerned when cost increases are accompanied by restrictions.
And we had a conversation earlier about incentives and what kind of incentives work and what dont work. One of the things that came through loud and clear in our work, and I would assume in Dr. Goetzels work, is that people are much more comfortable and amenable to positive incentives than negative incentives. What makes people crazy is the sense that youre taking choice away.
So when we presented options for incentives and other kinds of things that were more about youd be taking something away from people, peoples attitude was, wed much rather pay more money for who we want to see than have you say take all of these providers out of the network, or dont let me have access to this whatsoever. You get much, much stronger negative reactions then when you give people sort of more graduated incentives and things that, where they feel like they still have a choice. You may be asking me to pay more, now you found a way to help me understand a little better why I should do this, but at least I still have a choice. And on the notion of self- efficacy, its a pretty important component of how people see the world, its still feeling empowered and capable of making their own choices.
And so that was one of the things that also really came through, is that this frustration that - and theres sort of an irony here that sometimes employers and the things were talking about doing can make people feel disempowered.
It was a notion that changes were being made, options were being taken away, and shifting responsibility to them, but they didnt have the tools, they didnt really understand where this was coming from, they werent entirely sure they understood what all the science and evidence was about, and so they felt like they were losing control, and thats what people would tell us in the groups, its like were - youre not giving me control, suddenly Im feeling like its one more thing, I dont really understand how to do this, and now Im actually feeling less powerful than I did before. And I think, obviously, theres some great interventions out there that I think help people sort of overcome that. But again, I think its just important to understand that thats a lot of peoples mental and emotional starting point. And we ought to be thinking about how do we make sure we keep peoples self-efficacy high and improve self- efficacy.
The other piece is that really asking employees to use evidence-based health care and to think about these tools and interventions and behavior changes is really about asking them to become actively involved in their health-related decision making and behaviors.
If you think about it, and this is not just true for people for chronic disease, we want people to be using and applying information about staying healthy, preventing disease, managing disease, we also want them using information to think about the treatments their providers are suggesting to them, are they the right treatments, are they not the right treatments, we want them thinking about issues, is this cost-effective treatment, is this high-quality treatment? Theres a range of things were asking them to make sense of and kind of pull together in terms of their behaviors. And we couldnt get into all of these behaviors, so we have just a little bit of slice here, but certainly some of our research shows that they - and certainly in the focus groups and the interviews, folks lack experience and are sometimes intimidated by these behaviors.
And so just as an example - and we asked other questions, too, so this is just a small slice of some of the things we asked. But we asked people, have you brought information to the doctor, have you taken notes during a medical visit, brought friends or family members to a medical visit, brought a list of questions.
So you can see that 60 percent never brought in information, 55 percent never took notes, you know, theres really large percentages of people who havent done things.
What it really gets down to I think is, its hard to challenge the traditional patient/physician relationship. Patients are used to relying heavily on their doctors, and they can feel vulnerable, it can be hard to ask these questions, and we all know this and we know this is important, right, and a lot of what we just heard earlier is about how these interventions have to be multi-faceted, and where physicians have to be on board.
And Im not saying here its all about the physician, but in many cases what were asking people to do requires a high level of self-efficacy, requires - often times were suggesting going in and talking to physicians about some of these issues, and physicians can sometimes have a negative reaction.
I dont have something here; we did some multi-variete analyses, and we really - we basically - broke out into different cohorts of people, high information seekers to non-information seekers, and we correlated with various kinds of things, and what was really interesting to us is, the folks who had exhibited and actually engaged in these behaviors most were the ones who also experienced some real barriers to physicians, which I dont have here, which is basically, have you ever had any trouble going in and talking to your physician, because a physician seemed rush, or the physician seemed rude to you and cut you off, or you didnt know how to ask questions. It was interesting, the folks who had exhibited and done these behaviors most had experienced these problems more than anybody else, because theyre the folks going into the physician and having these conversations.
The last little data point, and I know this probably seems obvious, but still its - being active is hard. And, you know, 77 percent of our survey respondents say they were attempting to make a lifestyle change; 48 percent said it was moderate, 38 small or very small, but the bad news is, no matter how they viewed it, they all thought it was hard or very hard.
Back to this notion of the environmental and the incentives and the other constraints are really important. If peoples self-conception is virtually everything theyre trying to do is hard, its not very likely theyre going to do it or be able to sustain it.
And again, its just, to understand, thats their experience and their perception and thats an important thing to attend to. Im not going to spend too much time on what we did. We created a tool kit, it was really a convergence between employers felt this is what we really need help communicating about and where we felt employers really need help communicating from. And we really tried to think about communication and information, not as a social marketing campaign, heres a three word message, now go do it, darn it anyway..
But we really tried to think about how can we help people understand some key concepts, break down some of those biases and barriers to hearing the messages and the information that youre trying to reach people, help to educate them, but also move them to action.
And so our approach was to say, no, this is not just a 30 second spiel, but also to create something highly adaptable for employers who know their audiences better than anybody else. So theres sort of base materials for them to use and try to put into practice. And Ive just included a place where you can go see and learn more about it if you so choose. Thank you very much.
Paul Ginsburg: Id like to encourage people to start thinking about questions. I dont have much time to ask a few of the panel, but I will while youre getting ready, and if you have cards, pass the cards in. One question to Ron Goetzel. You know, one thing I got from your talk is how long in the development has been of effective methods on the part of employers of promoting health and wellness, and now we have a fad that all employers decide this is what they should be doing. You mentioned that a lot of the things theyre doing are unlikely to be effective. What are the scenarios you can sketch out as far as, you know, the good and the bad of what might happen from this point going forward?
Ron Goetzel: I think there is a window of opportunity right now where employers can apply evidence-based programs and do things effectively and see results, and that in itself will feed on itself so that more and more of these programs will proliferate and there will be advances and there will be more experimentation and more development of effective programs.
On the other hand, you can also see the opposite happening, where employers get sold a bill of goods that theyre going to produce a return on investment of three to one in three months, and they dont see it, and then they throw the baby out with the bath water and they dont buy - they dont believe it and it is a fad, as you just said. So I think there is a role for government and policy to highlight and accentuate the programs that actually do work, that are effective, and to measure the heck out of them, and to document that these programs are effective as opposed to relying upon anecdotal evidence, which often times is wrong or misleading.
Paul Ginsburg: Actually, as a follow-up, how much of a barrier is it that sometimes they can measure the savings in medical costs, but they cant measure, you know, the productivity, the presenteeism, et cetera?
Ron Goetzel: The methods for measuring absenteeism and presenteeism are advancing dramatically. The instrument that we use now is the work limitations questionnaire developed by Debra Lerner at New England Medical Center, Tufts University, which has undergone very systematic validity reliability testing, and its been used in many, many studies. Were using it in a number of our research studies. A fairly effective tool for measuring presenteeism.
Were also doing studies now that look at self- reported absenteeism versus administrative data, and are finding, in most cases actually, theres a fairly good concordance in terms of self-report and administrative data. So those measures and metrics are now being collected in addition to health care. And, in fact, when you look at cost savings, theyre additive, so its not just health care alone, but you can now add savings for absenteeism and productivity.
Paul Ginsburg: Michele Heisler, I had a question. Youve sketched out a lot about how hard it is to do effective delivery, and I mean whats involved, how hard it is, and I dont know that you gave us your thoughts about how to try to bring this about; where should society be looking?
Michele Heisler: Well, I think there is a lot that can be done. I think even - I think whats helpful is, once you get a sense of what the components are, it doesnt have to be high tech. I mean I think, as you know, from the recent New England Journal survey, I think less than 15 percent of practices have electronic medical records.
But there are ways you can develop; you can start by developing a simple registry. And so there are - I think theres a lot of lower tech things that also are effective in terms of organizing your practice, even if its pencil and paper, getting a sense of the registry, even if you just have a medical assistant, thinking of teams and how you can work more effectively. So I think once we get - certainly theyre ideal systems. I mean the VA is an ideal system. Im a VA doctor, and as I was saying earlier, I would not practice outside the VA now, you know, its unbelievable. You know, someone gets care in Arizona, I click on, I look at all the care they got in Arizona, I see all the subspecialties, so certainly integrated systems can do a lot, large populations.
But I do think we do have - I think its true that we have to think about larger issues of reimbursement to really get there. Incentives matter, as a number of the economists have stressed, incentives matter, and I think we all have to look at the fact that reimbursement does not reward prevention, reimbursement rewards high-tech procedures once complications have occurred.
So the incentive structure is very much toward paying for procedures once complications have occurred. Its also true that these key coordination roles, that increasingly doctors are going to have to play in this very fragmented health care system we have. So weve got to think about, you know, can we start coding for e-mail exchanges, phone call exchanges, follow-up, physicians and health care systems currently, all that active gathering up discharge summaries and specialist reports, none of that is being reimbursed. And so I think ultimately, payers need to think about, you know, what are the incentives of restructuring reimbursements so that there are incentives to introduce these necessary changes.
Paul Ginsburg: Yeah; actually one of the things that struck me is that our primary care work force is so small in relation to the job that you sketched out, it seems as though long term maybe reimbursement changes can rectify some of that, but maybe the more effective way would be to change our payment systems to be able to bring more non-physicians, others at various levels who work in the practices to do these functions, and I was wondering, do you see much of that at the VA, which you described as ideal?
Michele Heisler: I completely agree with that. I mean I think one can argue that a lot of the excellent primary care functions can be played by nurse practitioners and physician assistants. I think theres a - I have a lot of questions about this notion that theres a scarcity of physicians in primary care, because we have a lot of other health care team members that can be much more effectively deployed. And I think you do see that in the VA. In the VA you have a lot of - and again, what are the incentives; the VA has an incentive to keep its patient population healthy, because they know that that 30 year old veteran is still going to be in the system when theyre 70.
So as many of you know, the VA has invested a huge amount since the mid-90s in improving preventive and primary care, and a lot of that has been through having more case managers. So, for example, we talked about clinical inertia; as a physician, I dont mind starting insulin. You know, I talk to the patient, certainly I need to - but most patients - I mean I think a lot of resistance to insulin is from the physician, frankly. People say, oh, my patient wouldnt start insulin; but really, theres a lot of inertia because its complicated to start a patient on insulin. They need to be educated and using the monitor, they need a lot of support.
In the VA, when I need to start insulin, Ill talk with the patient, theyll be like, okay, yeah, Ill give it a try. I then immediately refer them to a case manager who does all of the education. Theyre much lower cost, its true, they can spend 40 minutes to provide that education. I also know if a patient has high blood pressure, I can start him on the blood pressure medication and have a wonderful nurse case manager follow up with that patient in two weeks.
So again, we have a whole team, we have many clinical pharmacists, we have medical assistants, theres a lot of - again, speaking of low cost, practices are - and Im sure Dr. Clancy can talk about this more, of individual practices better using medical assistants, having medical assistants develop action plans for patients, assess what their self-management goal is, you know, calling up in two weeks to say hows it going on your action plan.
So again, it doesnt all require very high-tech, expensive things. Similarly, peer support interventions; a recent systematic - review showed that having community health promoters is very effective, in some ways maybe even more effective than health care professionals, because the social distance is much less. If someone from my neighborhood, who I grew up with, whos from the same town in Mexico that Im from, comes and talks to me and we can share strategies for managing chronic disease, that likely is going to have a much bigger impact when some doctor who is very different from me says the same thing.
Paul Ginsburg: Good. Im going to go to questions. Is there anyone on the panel that wanted to say something else? Okay, maam.
Lynda Flowers: Good afternoon; Lynda Flowers, AARP Public Policy Institute. And I want to thank each of you; this is really a terrific panel, I really enjoyed it, and I thank you all. I have a comment for Dr. Goetzel and a question for Dr. Heisler. Ron, I hope youll be true to your promise and describe some of the key characteristics of the most successful workplace wellness program.
And then for Dr. Heisler, you mentioned the expanding role of other types of health care personnel in chronic disease management, and you specifically mentioned nursing and pharmacy. And so my question is, do you think that medical education is changing so that the physician community is prepared to embrace and support these expanded roles, particularly when they are directly reimbursed?
Michele Heisler: Thats an excellent question. I think theres been some movement in medical education to train medical students in working more effectively with teams. Certainly theres much more, at least an introduction to the chronic care model and the importance of teams. And certainly in residency training, were seeing a lot more of, you know, how are you working effectively with clinical pharmacists, with nurse practitioners.
As you can imagine, these fields are territorial, so questions of reimbursement are thorny, and people get threatened. And it may just be that the changing situation forces it. I mean the fact is, I have wonderful medical students, I have wonderful residents, none of them are going into primary care, and theyre not going to, and its not just because of poor reimbursement, its because they dont want to have a 15-minute visit overwhelmed by paperwork.
And so I think, you know, I dont think its just reimbursement thats going to get more physicians to go into primary care. So I think whats happening is that people are recognizing that theyre going to need to have more nurse practitioners and physician assistants.
And I think increasingly medical students, even those who are going into primary care say, well, maybe my role as a general internist is to take care of the complicated patient with multiple medical conditions, and maybe it makes sense for a nurse practitioner and physician assistant who, frankly, often get better training in nutrition and behavioral counseling, and I think that has to change, because a lot of what we all need to do is be better behavioral counselors. So I think that the reality is changing attitudes.
Paul Ginsburg: Actually I want to make a comment that, from the experience Ive had in dealing with specialty societies and over time my sense is that physicians are quite willing to delegate to other people when theyre in their practices. If its someone whos going to compete with them and have their own direct reimbursement, thats the opposite, then they fight that.
So, in a sense, its something where, I guess some of these other groups have to say, you know, is there a future involved in working with physicians in their practices, or do we want to hold out to work independently. Ron, do you want to answer that?
Ron Goetzel: Sure; and Im going to start with environmental interventions and going back to Eric Finkelsteins comments about what employers can do in terms of changing the workplace environment. I just listed a bunch of things that employers are doing that include walking trails and greenways, flex time, and schedule flexibility in terms of coming in at different hours of work and also being able to take time off for physical activity, shower facilities, bike racks, vending machines with healthy food options, cafeterias with healthy food options, and also differential pricing, essentially charging $15 for the cheeseburger, and you know, 20 cents for the celery, pointed decision signs in stairwells, slow elevators, thats been tried at Sprint, for example, building fitness centers, billing for physical activity, thats true for some consulting firms, where you can actually bill your time to going to the gym to work out, partial reimbursement for community health promotion programs. At a broader basis of policy level, and were working with Dow Chemical on this, is providing site goals for the managers, the leaders of sites, and having part of your bonus payment based upon your ability to meet site goals which are health and wellness related.
Senior management support, things like that, then we get into the more individualized interventions that include health assessments and screenings, in accordance with U.S. Preventive Services Task Force guidelines, triage and appropriate risk reduction programs, self-care, self-management, motivational interviewing, those kinds of things are very effective relating back to the community resources, and then ongoing measurement and evaluation of these programs on a surveillance basis.
Some things that have not been tried, kind of a top down approach. What Id like to see happen is that the senior management of a company be given certain health goals, and they need to achieve those first before they expect everybody else to achieve those goals, to see how hard it is, and also then to be motivating in terms of getting the culture to change so that it becomes much more of a healthy company culture.
Lisa Summers: I have to echo - a wonderful panel. My name is Lisa Summers and Im with the National Partnership for Women and Families. And Im with our health team, but we also have a very active work family team that works a lot on paid sick days and family medical leave. And my question was sparked by Dr. Carmans slide about consumers being suspicious of employers motivations. And my question is, do you have a sense from your research, or do any of you know, is there any research that would show an employers support of paid sick days or family medical leave perhaps counter that employer - employee distrust of these kinds of programs; do you have any sense, or has anybody really looked at that?
Kristen Carman: Oh no, absolutely; I mean Im sure Dr. Goetzel can talk about it. But I didnt get a chance to talk about our tool kit very much, but one of the key components we included was materials that employers can - theres sort of two components, one is stuff to help them think about how to think about their audience. Youve got to know your audience to communicate with them.
And then theres direct materials they can use, but they have to adapt them, and we did it for a very specific reason. Every set of material includes sort of two pieces, one is what you can do, talking to the employee, heres what you can do, heres what were doing.
So every material says, heres what were doing to get quality of care, get you this, you know, wise resources for your dollars, because what employees need to hear from employers and what we found in the testing the materials, which we went through five rounds of testing with about 60 individuals, unionized and non-unionized, is that one way to overcome the sense of being inundated and overwhelmed and get over suspicion is to show that employers are doing things themselves. So we give them lots of examples of things they could be doing to support employees and being able to engage in these different kinds of activities.
So while our materials arent, you know, what are the best economic incentives, because that wasnt our job, our job was to help employers communicate with employees. And one of the critical things is to tell them what youre doing and to do things that support them. And when you do that, you start breaking down some of those barriers and some of that bias, thats exactly right, and thats why we did it in such a way that essentially forces them to think about the issue.
You cant just take our materials and push them out there because we wanted employers thinking about these issues and adapting and talking to their employees about what they were doing. And, Dr. Goetzel, if theres anything that youd add.
Ron Goetzel: I agree; I think youve got to be very transparent and show that this is a combined effort. And, you know, one things that employers dont do enough of is to ask the question, have the employees ask the question, whats in it for me, kind of whats my ROI, what do I get out of this, and that has not been very well communicated, but I think there are possibilities for employers to do much more of that.
Kristin Carman: And employers really surprisingly often times arent communicating as much as they can be about what theyre doing, its really kind of amazing, and it just makes a big difference to do that to people, to feel like were in the same boat then, okay. On the notion of self-efficacy and motivation, Im not on my own, youre here to help me, that makes a big difference.
Caroline Poplin: I wanted to get back to the point about patients with multiple chronic conditions, I think thats where the doctors role is absolutely central, putting heart disease together with kidney problems together with congestive heart failure and diabetes and arthritis. One thing that no one has talked about is the way the coding system was set up by the AMA, a visit is based on the treatment of one acute problem. Two- thirds of the value of the visit is the history and the physical, which are not very important in chronic diseases, and thats why doctors dont treat them. If the person comes in for a cold, when you check his sugar and his blood pressure and everything else, you dont get paid for any of that, or very little, and thats an easy thing to fix, because it operates out of Medicare. If instead you said, if this patient has three of the following ten chronic conditions, thats a level five coming in, thats a person for whom you get more.
A healthy person who comes in for a urinary tract infection or allergies, youre going to get paid less for that, regardless if you do a big, elaborate history and physical. I think that its - the coding system is based on 19th century, how doctors always did things, history, physical, diagnosis, and assessment, and plan.
I think that would - doctors want to be good doctors, and they want to treat the diabetes and the hypertension, but the patient came in because his knee hurt, and you have to treat that first, because otherwise, the patient will never leave.
But the more chronic conditions we treat in a visit, the more we should get paid. And as I say, thats an easy fix, you just change it in Medicare.
Kathy Witgert: Hi, Im Kathy Witgert from the National Academy for State Health Policy. Dr. Heisler mentioned that the VA has great motivation to treat chronic conditions because youre going to keep seeing these patients for years and years. But I just changed jobs, so with businesses, what is motivating businesses to get involved with health promotion, and is there anything we can learn on the public-sector side, where we also see a lot of cycling of patients on and off of programs?
Ron Goetzel: Well, first of all, businesses today, especially with the economy hurting, are seeing less and less voluntary turnover, and people are holding onto their jobs. So, especially in large companies, manufacturing companies, people are there for life. In smaller companies, there is, obviously, much more of a churn, but theres also opportunities for short-term investment in programs, and also short-term returns.
But stepping back from all of that, people dont switch communities very often. They may switch jobs, but they dont go out of New York or Washington, and so theres a pool of employees in that community that are cycling through employers within a certain industry. And, you know, you probably are going to get people from that pool, and for you to say, I am going to be hard nosed about it and not do anything and Im going to let somebody else do something really doesnt make any sense, because these are the people who are essentially the workforce, and by the way, theyre more likely to come work for you if they think that you have a healthy company culture.
Paul Ginsburg: Melanie, do you want to comment on Medicaid beneficiary churn?
Melanie Bella: Sure; in Medicaid, for the folks were talking about, theres not as much churns, because I mean once they meet the disability definition, theyre pretty much on the programs. And so on the moms and kids side, though, that is quite different. And so particularly for high-risk pregnant women and for kids with asthma, you see a lot of cycling and a lot of inefficient spending coming on and off.
A couple of states have talked about taking the multiple health plans and developing prevention pools, if you will, or some way of aggregating the cost in savings, recognizing that theres going to be a churn across the plan, so that theres a shared investment and a shared return. I dont know that any of this has gotten off the ground, but it seems like a fairly good idea. And, you know, you think about how you could do that in a regional area where youre doing cross payer investment and health of a population, that all of you are going to touch at some point, maybe theres hope.
Paul Ginsburg: Actually, this is a good time for me to - I had a question based on your presentation, where youre talking about a lot of whats being done with chronic care by some programs, and it occurred to me that with Medicare part D, with the transfer of the responsibility for prescription drugs by a lot of Medicaid beneficiaries, certainly the dual eligibles to Medicare, and much less access to the data on what drugs - how much of an impairment has that been to these efforts?
Melanie Bella: Beyond a significant impairment. I mean a critical hindrance to the ability to have a really good picture of whats going on from a care management perspective, and I think youve seen that, not only from Medicaid purchasers, but youve seen it in some of the Medicare demonstrations, where some of the entities werent able to access the part D data if they werent the entity providing the services. CMS, to its credit, is trying to fix that, trying to expand access. I think its slow going, but I think understanding of the need is certainly there. But it is, obviously, as you know, especially when youre looking at the profile of these patient populations, the ability to, A, first know about all the drugs, and then B, begin to manage it, is critical.
Paul Ginsburg: Sure; sir, did you have a question?
John OBrien: I just wanted to thank all you again, like everyone else, for an excellent presentation. Im John OBrien, Im a pharmacist, and my question is actually for Melanie. Given your leadership and what weve heard from Dr. Heisler and the information gaps from Dr. Carman, do you see any way that Medicaid can get over paying pharmacists to be formulary cops and academic detailers and instead help patients be med coaches, to make responsible health care decisions?
Melanie Bella: Certainly there is a role for pharmacists, and I know some state Medicaid programs are paying pharmacists to do some of the complex care management for the patients and are rewarding a partnership between a care team or the inclusion of a pharmacist on a care team, so I think its being done some places. And certainly, if it can be demonstrated that it works, you know, opportunities to disseminate that information should be persuasive to other Medicaid agencies.
John OBrien: Is there a best way to share those best practices information - is there a particular way to frame it that might be most useful to other states?
Melanie Bella: Theres, you know, theres several venues. Our organization is promoting best practices, the National Association of State Medicaid Directors promotes best practices, NGA promotes best practices. I will tell you, similar to consumers that are skeptical of information, a lot of the best practices, I think the source of funding to -- that is verifying that its a best practice sometimes comes into play for Medicaid purchasers, so the more that its objective, the easier its going to be I think to get people to change payment policies across the board.
John OBrien: Thank you.
Paul Ginsburg: Thank you. This would be time for me to thank a lot of people that made this - first, our funders, PHARMA, DMMA: The care Contium Alliance and the American College of Preventive Medicine, various HSC staff that have made this conference successful, especially Alwyn Cassil, who did the substance of planning the conference, and finally our panel here.
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Melanie Bella, senior vice president for policy and operations at the Center for Health Care Strategies (CHCS), leads the organizations efforts to improve the quality of care for people with chronic illness and disabilities, including work on chronic disease management, managed long-term care, and special needs health plans for dual-eligible beneficiaries. Prior to CHCS, she served as Medicaid director for the state of Indiana from 2001 through 2005. During her tenure as Medicaid director, one of her most notable accomplishments was the Indiana Chronic Disease Management Program. Bella serves as a health care adviser to Harvard Universitys Kennedy School of Government Innovations in American Government Awards program and is a member of the National Committee for Quality Assurances Geriatrics Measurement Advisory Panel (GMAP). She earned a masters in business administration from Harvard University and a bachelors degree from DePauw University.
Kristin L. Carman, Ph.D., is co-director of the Health Policy & Research Program at the American Institutes for Research (AIR), where she leads a team of 25 health services research professionals conducting research on health care quality, access, communications, financing, and consumer engagement. Carman is a nationally known expert on reporting information on quality of health care and the development and testing of data displays and written materials that translate medical evidence for use by consumers and purchasers. She is a co-principal investigator on the Agency for Healthcare Quality and Research (AHRQ) project known as Consumer Assessment of Health Plans and Providers Study (CAHPS II) to design and evaluate consumer-reported measures of health plan and provider performance. She also leads a California HealthCare Foundation project to create a communication toolkit to help employers educate employees about evidence-based health care. Carman recently led an Institute of Medicine (IOM) working group on communicating about evidence-based medicine as part of the IOMs larger Roundtable on Evidence-Based Medicine. An additional focus of her work is assessing how health care organizations perform and how best to enable organizations to improve performance. Prior to joining AIR in 2001, Carman was at RTI International, where she conducted studies on the assessment of health plans and reporting of quality information. She received her Ph.D from Northwestern University and worked as a legislative analyst for the Illinois General Assembly for many years before entering graduate school.
Carolyn M. Clancy, M.D., was appointed director of the Agency for Healthcare Research and Quality (AHRQ) on Feb. 5, 2003. Prior to her appointment, Clancy had served as AHRQs acting director since March 2002 and previously was director of the agencys Center for Outcomes and Effectiveness Research (COER). Clancy, who is a general internist and health services researcher, is a graduate of Boston College and the University of Massachusetts Medical School. Following clinical training in internal medicine, Clancy was a Henry J. Kaiser Family Foundation Fellow at the University of Pennsylvania. She was also an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond before joining AHRQ in 1990. Clancy holds an academic appointment at George Washington University School of Medicine (Clinical Associate Professor, Department of Medicine) and serves as senior associate editor, Health Services Research. Dr. Clancy has served on multiple editorial boards (currently Annals of Family Medicine, American Journal of Medical Quality, and Medical Care Research and Review). Clancy has published widely in peer-reviewed journals and has edited or contributed to seven books. She is a member of the Institute of Medicine and was elected a master of the American College of Physicians in 2004.
Eric Finkelstein, Ph.D., is a health economist and director of RTIs Public Health Economics Program. His research focuses on the economic causes and consequences of health behaviors, with a primary emphasis on behaviors related to obesity. He recently completed a text, titled The Fattening of America, How the Economy Makes us Fat, If It Matters, and What to do About It, and frequently speaks at conferences about the economic impact of obesity and strategies for reducing this burden. Before joining RTI, Finkelstein was an Agency for Health Care Policy and Research fellow and research scientist with the University of Washingtons Department of Family Medicine. He received his doctorate in economics from the University of Washington.
Paul Ginsburg, Ph.D., a nationally known economist and health policy expert, is president of HSC, a nonpartisan policy research organization in Washington, D.C., funded in part by the Robert Wood Johnson Foundation. Ginsburg is a noted speaker and commentator on changes taking place in the health care system. His recent research topics have included cost trends and drivers, Medicare physician and hospital payment policy, consumer-directed health care, the future of employer-based health insurance, and competition in health care. In 2007, for the fifth time, Ginsburg was named by Modern Healthcare as one of "The 100 Most Powerful People in Healthcare." He received the first annual Health Services Research Impact Award from AcademyHealth, the professional association for health policy researchers and analysts. He is a founding member of the National Academy of Social Insurance, a public trustee of the American Academy of Ophthalmology and served two elected terms on the board of AcademyHealth. Before founding HSC, Ginsburg was the executive director of the Physician Payment Review Commission (PPRC), created by Congress to provide nonpartisan advice about Medicare and Medicaid payment issues. Under his leadership, the PPRC developed the Medicare physician payment reform proposal that was enacted by Congress in 1989. Ginsburg previously worked for the RAND Corp. and the Congressional Budget Office. He earned his doctorate in economics from Harvard University.
Ron Z. Goetzel is both the director of the Emory University Institute for Health and Productivity Studies and vice president of consulting and applied research for Thomson Reuters Healthcare. Over the past 20 years, Goetzels work has focused on large-scale evaluations of health promotion, disease prevention, demand and disease management programs. He is principal investigator (PI) for Medicares Senior Risk Reduction Demonstration and New Opportunities for Healthy Aging in Medicare project. He is also PI for a project sponsored by the National Heart, Lung and Blood Institute focused on obesity prevention and management at the worksite. For the Centers for Disease Control and Prevention, Goetzel is the PI for a New York City-based project supporting collaboration between the private and public sectors in health promotion and disease prevention initiatives directed at employers. As PI for a study funded by the National Association of Chronic Disease Directors, Goetzel identified the characteristics of promising practices in workplace health and productivity management programs. Before joining Thomson Healthcare (formerly Medstat) in 1995, Goetzel was vice president of assessment, data analysis and evaluation Services at Johnson & Johnson Health Care Systems. Earlier in his career, Goetzel was the medical school education program evaluator at the Albert Einstein College of Medicine, where he was appointed to the psychiatry faculty. Dr. Goetzel earned his doctorate in organizational and administrative studies and his M.A. in Applied Social Psychology from New York University (NYU), and his B.S. degree in Psychology from the City College of New York (CCNY). He is located in Washington, DC.
Michele Heisler, M.D., M.P.H., is an associate professor of medicine and health behavior and education at the University of Michigan and a research scientist at the Veterans Affairs Health Services Research & Development (HSR&D) Center of Excellence. She is also co-director of the University of Michigans Robert Wood Johnson Foundation Clinical Scholars Program and a member of the Measurement Core of the Michigan Diabetes Research and Training Center. Her research focuses on patient, clinician, and health systems factors that influence patients chronic disease self-management, including medications adherence. She has particular expertise in developing and evaluating health system and behavioral interventions to enhance self-management support for patients with chronic diseases. She currently is principal investigator on several federally funded interventions testing different models and practice changes to improve support for patients diabetes and heart failure self-management, leading to improved health outcomes. Heisler is a graduate of Harvard Medical School and received a masters of public health degree from Princeton University.